Knowledge Brief Health, Nutrition and Population Global Practice BASIC PROFILE OF EARLY CHILDBIRTH IN MOZAMBIQUE Chata Malé and Quentin Wodon March 2016 Child Marriage Series with Education Global Practice KEY MESSAGES:  Measures of early childbirth are high in Mozambique. The share of women ages 18-22 who had a child before 18 is 39.0 percent and it has increased over time. The share of women who had a child before the age of 15, at six percent, has however decreased.  Early childbirth is associated with lower wealth, lower education levels, and higher employment. These are however only correlations, not necessarily causal effects. In order to design programs and policies to reduce the Box 1: Brief and Series Primer prevalence of early childbirth, information is needed on its How is child marriage defined? Child marriage is defined as a trend over time, where it is most prevalent in a country, marriage or union taking place before the age of 18. and what the characteristics of girls giving birth early are. Why a series on child marriage? Child marriage has Measuring early childbirth is needed to inform policy. significant negative impacts – not only for girls, but also for a range of development outcomes. Demonstrating these impacts Early pregnancy and childbirth are important issues in will assist governments and others to make the case for intervening to reduce the practice. many countries. Early childbirth is associated with higher health risks for the mother and the child as well as higher What are the topics discussed in the series? The series fertility. It may lead girls to drop out of school. In most looks at the impacts of child marriage on health, population, countries, most early childbirths take place after marriage. education, employment, agency, and violence, among other But in some countries, it may also often take place without outcomes. The welfare, budget, and non-monetary costs of child a marriage or union. To reduce the prevalence of early marriage are estimated. Legal/institutional aspects and options childbirth, specific programs and policies are required, for to reduce the practice are also discussed. which basic information is needed. Using techniques inspired by the poverty literature, this brief provides a What is the question asked in this brief? The question is: How widespread is early childbirth, not only in terms of the share basic profile of early childbirth in Mozambique. The brief of girls affected by it, but also in terms of how early births occur? documents the extent of early childbirth, its trend over time, in which areas it is most prevalent, and what some How is the question answered? Measures and a profile of of the characteristics of the girls affected by early early childbirth inspired by the literature on poverty are provided. childbirth are. The brief is part of a series of standardized briefs on this topic for several countries. Page 1 HNPGP Knowledge Brief  Four in ten women have an early childbirth. The consequences of early childbirth for girls and their children are not the same whether girls have a child at 12 The analysis relies on data from the latest Demographic or 17. Measures inspired from the poverty literature help and Health Survey (DHS) for Mozambique for 2011, the in capturing how early girls have children (see the annex). latest DHS available. Table 1 provides basic statistics on The headcount (H) measures the share of girls with an the age at first birth. Two samples are considered: women early childbirth. The early childbirth gap (ECG) measures ages 18 to 22, the youngest age group that can be used the “depth” of early childbirth, taking into account how to measure early childbirth1 and women 18-49 (the early girls have children. The squared gap (SG) puts even women’s questionnaire in the DHS collects data for more weight on the girls who have children very early. women up to age 49). Almost four in ten women have their first child before 18, and six percent do before 15. Early childbirths have increased over time. There is a decrease in the mean age at first birth between the 18-49 sample and the 18-22 sample. This is in large Table 3 provides trends over time in the measures of part because many women ages 18 to 22 did not yet have early childbirth inspired by the poverty literature. Consider a birth and is therefore not worrying in itself. But as will be shown below, there is also a slight increase in the first the age group 18-22. In that age group, almost four in measures of early child birth over time, which is worrying. ten women had their first child before the age of 18 (39.0 percent for the 18-22 age group). The early childbirth gap (CBG) is at 4.7 percent and the squared gap ( SG) at 0.8 Table 1: Age at First Birth for Women (%) 18-22 years 18-49 years percent for that group. By estimating the same measures No live Birth 31.0 11.3 on older groups, the table provides the trend in early 18 or Above 30.0 52.6 childbirth over time. There has actually been an increase 12 1.3 1.9 over time in early childbirth, at least comparing the 18-22 13 1.6 2.3 age group with the two oldest age groups. In other words, 14 3.1 4.1 as for child marriage, measures of early childbirth have 15 6.3 6.3 increased. However, the trends in very early childbirth 16 10.6 9.6 (before the age of 15) suggest a decline over time2. 17 16.2 12.0 Total 100.0 100.0 Table 3: Trend in Early childbirth (%) Mean age at 1st birth 17.1 18.8 18 years 15 years Source: Authors’ estimation. H CMG SG H CMG SG All 18-49 years 36.2 5.0 0.9 8.3 1.0 0.1 Most early childbirths take place after marriage. Age group 18-22 years 39.0 4.7 0.8 6.0 0.7 0.1 In Mozambique, there is a strong relationship between the 23-30 years 39.6 5.4 1.0 8.6 0.9 0.1 age at first birth and the age at first marriage as 31-40 years 31.7 4.6 0.9 8.7 1.0 0.2 communities do not look favorably at births out of 41-49 years 33.8 5.1 1.0 9.8 1.2 0.2 wedlock. Table 2 displays the shares of girls with an early Source: Authors’ estimation. childbirth according to four categories in terms of the timing (or absence) of marriage among women ages 18- The incidence of early childbirth in Mozambique in 2011 22. Most early childbirths take place after marriage, hence was higher than that observed 25 years ago, but there delaying the age at marriage is essential to avoid early has been a decline in very early childbirth. childbirth. Girls are more likely to have children early if they live Table 2: Marriage and Early Childbirth, Age 18-22 (%) in rural areas and are from poorer backgrounds. Share Early childbirth without marriage 9.2 Early childbirth before marriage 16.6 As expected, early childbirth is much more prevalent in Early childbirth in the same year as marriage 20.6 rural than in urban areas. There are also large differences Early childbirth at least one year after marriage 53.6 between regions, with the lowest measures observed in Total 100.0 the capital city of Maputo cidade, and the highest Source: Authors’ estimation. measures observed (according to the headcount index with the 18 years threshold) in Nampula, Cabo Delgado, and Inhambane. Early childbirth is less prevalent in 1 Maputo provincia. The ranking of the regions in terms of Early childbirth measures must be estimated on the population older than 18, because some younger girls who did not yet have a child by 18 could still have a child by the time they reach 18. It 2 is best to measure early childbirth as early as possible after the Note that the various measures have standard errors (not age of 18 to provide data on conditions as current as possible, shown here to save space). While some of the differences in the which is why the age bracket 18-22 is used here. trends over time are statistically significant, some are not. Page 2 HNPGP Knowledge Brief  the measures obtained with the 15 and 18 years Early childbirth is associated with lower education, thresholds is slightly different, especially for highest rates. illiteracy, and higher labor force participation. Table 4: Early childbirth by Location, Age 18-22 (%) Table 6 provides data on early childbirth by level of 18 years 15 years education of the women, as well as literacy. Early H CMG SG H CMG SG childbirth affects education attainment negatively, All 18-22 years 39.0 4.7 0.8 6.0 0.7 0.1 because girls often drop out of school when they have Region their first child. The causality goes the other way as well, Niassa 39.9 5.3 1.0 8.3 1.1 0.2 as the ability to pursue one’s education may help delay Cabo Delgado 43.8 5.7 1.0 9.3 1.1 0.2 the age at marriage and thereby the age at first birth. As Nampula 47.8 5.3 0.8 5.5 0.6 0.1 seen in table 6, early childbirth measures are strongly Zambezia 38.1 4.9 0.9 7.5 0.9 0.1 Tete 40.5 5.2 0.9 6.9 0.7 0.1 correlated with education levels. The same is observed Manica 41.9 4.7 0.7 5.2 0.6 0.1 when considering literacy where three categories are Sofala 35.5 4.7 0.8 8.1 0.9 0.1 considered: the woman cannot read at all, can read part Inhambane 42.4 4.6 0.7 3.5 0.4 0.1 of a sentence, or can read a full sentence. Gaza 35.8 3.6 0.5 2.7 0.2 0.0 Maputo provincia 30.4 3.3 0.5 3.6 0.4 0.1 Table 6: Early childbirth by Education Level and Maputo cidade 20.2 2.3 0.4 1.9 0.3 - Literacy Status, Age 18-22 (%) Residence 18 years 15 years Urban 32.0 3.7 0.6 4.4 0.5 0.1 Rural 43.3 5.3 0.9 7.0 0.8 0.1 H CMG SG H CMG SG Source: Authors’ estimation. Values rounding to 0.00 not shown. All 18-22 years 39.0 4.7 0.8 6.0 0.7 0.1 Education No education 44.4 5.9 1.1 10.6 1.3 0.2 Rural girls are more likely to have children early than Primary, some 46.5 5.6 0.9 7.2 0.8 0.1 urban girls, as is the case for girls from the bottom four Primary, compl. 40.2 4.1 0.6 2.7 0.3 - quintiles of wealth. The relationship between early Secondary, some 27.1 3.1 0.4 2.9 0.3 - childbirth, literacy, and education attainment is strong. Secondary, compl. 2.9 0.5 0.1 0.6 0.1 - There are also differences by work patterns. Higher - - - - - - Literacy Cannot read 46.4 5.9 1.0 9.2 1.0 0.1 Household welfare is measured through a wealth index Limited ability 40.6 4.5 0.7 5.2 0.6 0.1 with households categorized according to five quintiles of Full sentence 31.0 3.4 0.5 2.8 0.3 - wealth. Women who had a birth tend to be married, hence No card available 65.0 14.4 3.2 65.0 4.3 0.3 the level of wealth is that of the household in which the Source: Authors’ estimation. Values rounding to 0.00 not shown. women married, not that of the household or origin. Yet the quintile of wealth after marriage and first birth may not Table 7 provides data on labor force participation. One be very different from that of the household of origin. On would expect early childbirth to reduce women’s labor the other hand, since early childbirth measures are based force participation, for example through higher fertility. But on young women ages 18-22, their level of assets may be if early childbirth is associated with poverty, women may lower than would be the case later in life. In any case, the leave little choice but to work. Other effects could also be measures of early childbirth do not differ much between at work. In Mozambique, early childbirth measures are the four bottom quintiles, and it is only with the top quintile higher among women who work. In addition, the type of that early childbirth is much less prevalent. work associated most closely with early childbirth is work without cash earnings (in-kind benefits only), which may Table 5: Early childbirth by Quintile, Age 18-22 (%) be work with low productivity. 18 years 15 years H CMG SG H CMG SG Table 7: Early childbirth by Labor Force Participation All 18-22 years 39.0 4.7 0.8 6.0 0.7 0.1 Status, Age 18-22 (%) Wealth quintiles 18 years 15 years Poorest 45.4 5.0 0.8 5.4 0.6 0.1 H CMG SG H CMG SG Poorer 36.9 4.5 0.7 7.5 0.7 0.1 All 18-22 years 39.0 4.7 0.8 6.0 0.7 0.1 Middle 49.3 6.3 1.1 9.1 1.1 0.2 Working Richer 43.0 5.3 0.9 6.8 0.8 0.1 No 35.8 4.3 0.7 5.4 0.6 0.1 Richest 24.7 2.9 0.4 2.5 0.3 - Yes 44.2 5.3 0.9 7.1 0.8 0.1 Source: Authors’ estimation. Values rounding to 0.00 not shown. Type of work Not paid 44.4 5.1 0.8 6.9 0.7 0.1 Cash only 44.1 5.5 1.0 7.0 0.9 0.1 Cash and in-kind 34.0 3.7 0.5 1.0 0.1 - In-kind only 47.3 5.8 1.0 9.3 1.0 0.1 Source: Authors’ estimation. Values rounding to 0.00 not shown. Page 3 HNPGP Knowledge Brief  Conclusion The early childbirth gap represents the “depth” of early childbirth. It takes into account not only the share of girls who had their first This brief has provided a basic profile of early childbirth in child early, but also the mean number of years below 18 (or 15) Mozambique. Measures of early childbirth are high. The at which girls had their first child. This matters because even if share of women ages 18-22 who had their first child the share of girls who have their first child early does not change, there may still be improvements in the early childbirth before 18 is 39.0 percent and it has increased over time. gap if girls who have their first child early have that child a little The share of women with their first child before 15 is at six less early. percent, and this share has decreased over time. Early childbirth is associated with lower wealth and lower Finally, the squared early childbirth gap measures the “severity” education levels, and employment without cash earnings. of early childbirth. While the early childbirth gap takes into These are however only correlations, not necessarily account the average number of years of early marriage for girls causal effects. Other briefs in this series look at potential who have their first child early, the squared gap takes into causal effects. account the square of that number, thereby putting more emphasis on girls who have their first child very early. Together the three measures provide a better diagnostic of early childbirth References than the headcount index alone. The measures also have attractive properties that are beyond the scope of this brief (see Foster, J., J. Greer, and E. Thorbecke, 1984, A Class of Nguyen and Wodon, 2015). Decomposable Poverty Measures, Econometrica 52: 761–776. The headcount index, early childbirth gap, and squared gap are Nguyen, M. C., and Q. Wodon, 2012, Measuring Child Marriage, the first three measures of the so-called FGT class (Foster et al., Economics Bulletin 32(1): 398-411. 2014). Denote by q the number of girls who have their first child early and by n the number of girls in the overall population. Annex: Methodological Note Denote by yi the age at which girl i had her first child and by z the age threshold defining early childbirth (18 years of age, but a While many studies have discussed trends in child marriage, lower age threshold such as 15 can also be used to measure less work has been done on trends in early childbirth. When extremely early childbirth). The general formula for the FGT conducted, measurement of early childbirth (or early pregnancy) class of measures depends on a parameter α which takes a has focused on one simple statistic such as the share of girls value of zero for the headcount, one for the early childbirth gap, who have a live birth before the age of 18 or 15. Such statistics and two for the squared gap in: are useful, but they do not capture well the distribution of the  1 q  z  yi  age at first birth in the form of aggregate statistics that tell us P    about the depth and severity of the problem. Basic statistics on the share of girls having an early childbirth also do not facilitate n i1  z   testing for the robustness of comparisons of trends in early childbirth between countries, between groups within countries, This brief was produced as part of the Economic Impacts of Child or between time periods. Marriage study, a joint project of the International Center for Research on Women (ICRW) and the World Bank, which is supported by the Bill & Following the approach used by Ngyuen and Wodon (2012) for Melinda Gates Foundation and the Children’s Investment Fund child marriage, this brief and its companion paper available upon Foundation (CIFF). More details on the research can be found at the project’s website: www.costsofchildmarriage.org. Partial funding for the request rely on methods from the poverty literature to measure work related to child marriage and education, labor force participation, early childbirth. Three measures are used: the incidence of early earnings, and program responses has been provided by the Global childbirth or headcount index, the early childbirth gap, and the Partnership for Education. Comments from Jeff Edmeades and Michele squared early childbirth gap. The headcount index is simply the Gragnolati are gratefully acknowledged. The opinions expressed in this share of the girls who have their first live birth before the age of brief are those of the authors only and need not reflect the views of the 18. The headcount index can be computed for other age World Bank, its Executive Directors, of the countries they represent. thresholds, such as 15 years of age. 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