Knowledge Brief Health, Nutrition and Population Global Practice EARLY CHILDBIRTH AND UNDER-FIVE MORTALITY IN THE DEMOCRATIC REPUBLIC OF CONGO Adenike Onagoruwa and Quentin Wodon June 2017 Child Marriage Series with Education Global Practice KEY MESSAGES:  In the Democratic Republic of Congo (DRC), one in ten children dies before the age of five; for children born of mothers younger than 18, the risk of is higher.  Controlling for socio-economic and other characteristics, being born of a mother younger than 18 increases the likelihood of dying before the age of five by four percentage points in the baseline model, as compared to otherwise similar children born of older mothers.  Box 1: Brief and Series Primer Early childbirth is associated with health risks for children, 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. groups. But the age of the mothers may also play a role. Early childbearing is 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 morbidity and under-five mortality. range of development outcomes. Demonstrating these impacts will assist governments and others to make the case for Young mothers often come from disadvantaged socio- intervening to 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 access to health facilities may be an issue. Girls who looks at the impacts of child marriage on health, population, have children early also tend to be less educated and education, employment, agency, and violence, among other may suffer from lack of agency within the household, outcomes. The welfare, budget, and non-monetary costs of child marriage are estimated. Legal/institutional aspects and options further reducing access to care. In addition, some girls to reduce the practice are also discussed. who give birth early may not yet be ready physiologically to give birth. The risk of obstetric fistula, for example, is What is the question asked in this brief? The question is: higher for young mothers. These various factors lead to How large is the impact of early childbirth on under-five mortality higher risks of under-five mortality for children born of and does it account for a large share of under-five deaths? young mothers. How large is the impact of early childbirth on under-five mortality? Does early childbirth accounts for How is the question answered? Econometric analysis of a large share of under-five deaths? These are the Demographic and Health Survey data is used to estimate the questions asked in this brief for the DRC. impact of early childbirth on under-five mortality. Page 1 HNPGP Knowledge Brief  Statistically, children from young mothers are three for the children by 3.9 percentage points in comparison to percentage points more likely to die before five. a delivery at 18 to 34 years of age (coefficient statistically significant at the one percent level). The difference in risk The analysis is based on data from the second of under-five mortality between mothers ages 18-34 and Demographic and Health Survey for the Democratic mothers above 35 is not statistically significant. Republic of Congo implemented in 2013-14 (in French, EDS-RDC II). According to the survey under-five mortality Deliveries at a young age increase the likelihood of under- remains high with one in ten children (104 ‰) dying five mortality for the children by 3.9 percentage points in before the age of five. But there has also been some comparison to a delivery at 18 to 34 years of age. progress over time, since the rate observed with the 2004 DHS was 158‰ and the rate with the 2007 DHS was Marginal effects do not change much when additional 148‰ (Republique Démocratique du Congo, 2014). controls are used (extended model). There is thus some evidence that after controlling for a wide range of other In this brief we focus on whether all children identified in variables, early childbirth may contribute to under-five the survey have died or not before reaching five years of age, and the factors that affect that outcome. This implies mortality, but prudence remains needed when interpreting relying on statistics computed in a different way from the the results given the risk of omitted variable bias (box 2). official under-five mortality rate, but the idea and orders of Table 2: Impact of Early Childbirth on Under-five magnitude are similar (to avoid a risk of confusion, we will Mortality use below the term “under-five mortality” but not the term Age at first marriage Baseline Extended “under-five mortality rate”). As shown in table 1, 10.32 model model percent of children born of mothers younger than 18 die Mother younger than 18 0.0393*** 0.0379** before reaching five years of age. The proportion, which Mother in 18-34 age bracket Reference Reference we refer to as under-five mortality, is 7.12 percent for Mother older than 35 0.00847 0.00645 children born of mothers 18 to 34 years of age. The Source: Onagoruwa and Wodon (2015). Levels of statistical difference in under-five mortality between the two age significance: *** 1%, ** 5%, * 10%. groups is statistically significant. For children of older mothers, the under-five mortality is at 8.06 percent. Box 2: Risk of Omitted Variable Bias Table 1: Under-five Mortality by Age of the Mother Early childbirth appears to be positively correlated with the risk Age of the mother Under-five Mortality of under-five mortality after controlling for other factors that may (‰) also contribute to mortality. This could indicate a causal effect. Mother younger than 18 10.32 However, other variables correlated with both early childbirth Mother in 18-34 age bracket 7.12 and under-five mortality not included in the analysis could be at Mother older than 35 8.06 the source of the correlation between early childbirth and under- Source: Onagoruwa and Wodon (2015). five mortality. Because of the risk of omitted variable bias, the results cannot be considered as fully conclusive regarding a Controlling for other factors, early childbirth still causal effect of early childbirth on under-five mortality. increases the likelihood of stunting substantially. A number of results from the regression analysis not The difference in under-five mortality between children of shown in table 2 are worth mentioning. The impact of the young and older mothers does not necessarily imply a education of the mother on the likelihood of under-five causal effect of the age at delivery, but it does suggest mortality is not statistically significant. Similarly, the that early childbirth may contribute to under-five mortality. impact of wealth on the likelihood of under-five mortality is To check whether controlling for other factors early not statistically significant, at least when measured childbirth is indeed associated at the margin with higher through the wealth quintiles. This is a bit surprising, but it under-five mortality, regression analysis is used (see the could be due to the fact that households in all four bottom annex for details on the methodology). quintiles are poor or near poor in a country like the Democratic Republic of Congo, and whether a household Table 2 provides key results with baseline and extended is extremely poor or simply poor may not make much of a models. The interpretation of the coefficients is in terms of difference on the likelihood that the child may die. A few marginal impacts in percentage terms. For example, a other effects are also statistically significant, as discussed statistically significant coefficient of 0.05 for a mother in the more detailed study on which the brief is based. younger than 18 would indicate that children of very young mothers have a likelihood of under-five mortality The evidence in table 2 suggests that early childbirth five percentage points higher than children of older increases the likelihood of under-five mortality. This is a mothers, controlling for other characteristics. With the direct impact controlling for other independent variables baseline specification, table 2 suggests that deliveries at a included in the models. Could early pregnancy and young age increase the likelihood of under-five mortality delivery also have an indirect impact on under-five Page 2 HNPGP Knowledge Brief  mortality through the effect of early pregnancy or delivery brief has provided estimates of the direct impact of early on some of the other variables that are used as controls in childbirth on under-five mortality in the Democratic the regression? For example, for some of the girls Republic of Congo using the latest DHS survey. More delivering a baby at a young age, early pregnancy has a than one in ten children under the age of five die; but for negative effect on education enrollment and attainment. children born of mothers younger than 18, the risk of Early deliveries, by increasing the number of children that under-five mortality is higher by 3.2 percentage points. women have, may also contribute to lower labor force participation for women and thereby lower household Because only a small share of deliveries are by mothers wealth. There could be such effects, but in terms of younger than 18, only three in 100 children deaths before magnitude, indirect effects are likely to be small in five can be said to be directly due to early childbirth. comparison to the direct effects in table 2. This is simply because in the full regression estimates for the correlates Controlling for socio-economic and other characteristics, of under-five mortality (not shown here), the effects of the being born of a mother younger than 18 increases the mother’s education and the wealth status of the likelihood of under-five mortality for children by close to households on mortality are not statistically significant, at least in the case of the Democratic Republic of Congo. four percentage points, as compared to otherwise similar children born of older mothers. Given the share of children born of young mothers, nationally for every 100 Early childbirth may also affect under-five malnutrition children who die before the age of five, three may die indirectly, for example through lower education attainment directly because of an early childbirth. This may appear for mothers, but these effects are likely to be smaller. low, but still represents a large number of children. Simulations suggest that about three in 100 deaths References for children under five are directly due to early childbirth. Bicego, G., & Ahmad, O. (1996). Infant and child mortality, Demographic and health surveys comparative studies No. The last step in the analysis of the impact of early 20. Calverton (Maryland): Macro International Inc . pregnancy and delivery on under-five mortality consists in Nasrullah, M., Zakar, R., Zakar, M. Z., & Krämer, A. (2014). Girl- assessing the potential reduction in under-five mortality child marriage and its association with morbidity and mortality of that could arise from eliminating early pregnancies and children under 5 years of age in a nationally-representative deliveries. This can be done by predicting (i.e. simulating) sample of Pakistan. The Journal of pediatrics,164(3), 639-646. the likelihood that children who were born of mothers younger than 18 would have remained alive if they had Onagoruwa. A. O. and Q. Wodon, 2015, Impact of Early been born of older mothers. In other words, we are Childbirth on Under-five Mortality in the Democratic Republic of considering the direct effects of the age of the mother on Congo, Mimeo, ICRW-World Bank Economic Impacts of Child under-five mortality, shifting in the data deliveries by Marriage Project. Washington, DC: ICRW and the World Bank. young mothers to deliveries at a later age, and observing Prakash, R., Singh, A., Pathak, P. K., & Parasuraman, S. the difference that this makes for under-five mortality (2011). Early marriage, poor reproductive health status of nationally. mother and child well-being in India.Journal of family planning and reproductive health care, jfprhc80. The simulations suggest that without early pregnancies and deliveries, the share of children dying before five Raj, A., Saggurti, N., Winter, M., Labonte, A., Decker, M. R., could decrease by 0.2 percentage point. This essentially Balaiah, D., & Silverman, J. G. (2010). The effect of maternal corresponds to the product of the marginal effect of early child marriage on morbidity and mortality of children under 5 in deliveries on under-five mortality (0.0393 in table 2) times India: cross sectional study of a nationally representative the share of children born of mothers younger than 18 (six sample. BMJ, 340. percent of children). Given the estimate of under-five Raj, A., & Boehmer, U. (2013). Girl child marriage and its mortality nationally, three in every 100 children dying association with national rates of HIV, maternal health, and before the age of five can be considered as dying due to infant mortality across 97 countries.Violence against the direct effect of early pregnancies and deliveries on the women, 19(4), 536-551. likelihood of under-five mortality. This may appear relatively low in comparison to the total number of children Raj, A., McDougal, L., & Rusch, M. L. (2014). Effects of young who die, but still represents a large number of children. maternal age and short interpregnancy interval on infant mortality in South Asia. International journal of gynaecology and Conclusion obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics, 124(1), 86. Early pregnancy and delivery may contribute to the risk of République Démocratique du Congo, 2014, Deuxième enquête under-five mortality for children, directly, or indirectly. This démographique et de santé (EDS-RDC II 2013-2014), Ministère Page 3 HNPGP Knowledge Brief  du Plan et Suivi de la Mise en œuvre de la Révolution de la practices polygyny; and (13) indicators of decision-making Modernité, Ministère de la Santé Publique, et MEASURE DHS, power for the mother in the household. Rockville, MD: ICF International. It is worth noting that the specifications used for modeling the Annex: Methodological Note correlates of under-five mortality are more parsimonious in terms of the independent variables included than the specifications There is an existing literature on the relationship between early used in a separate analysis by the authors for malnutrition using pregnancy (as well as child marriage) and the risks of infant, stunting as the main measure of interest. In principle, given that child, and under-five mortality. Much of the literature focuses on malnutrition is a key factor leading to premature death for South Asia (e.g., Bicego, 1996; Adhikari, 2003; Raj, 2010; Raj et children, one could argue that all correlates of under-five al., 2013; Raj and Boehmer, 2013; Prakash et al., 2011; malnutrition should also be used as correlates of under-five Nasrullah et al., 2014). The results suggest that children born of mortality. The issue however is that the rate of under-five young mothers are indeed at higher risk of under-five mortality. mortality in countries is much smaller than the rate of stunting. The models used tend to perform less well when very few of the Statistics comparing under-five mortality according to the age of observations take on a positive value for the dependent variable the mother may hint at the relationship between the two. But for (i.e., dying before the age of five). In addition, when many more assessing marginal impacts, regression analysis is needed. Part variables are used, there is also a much higher risk of perfect of the literature relies on survival models, which provide correlation (prediction) between some of the variables and the information on how long children survive given their dependent variable, in which case the independent variable will characteristics. The models are censored, in that if a child has be dropped from the model as well as the observations for which survived beyond five years of age, s/he is considered as having the outcome was perfectly predicted. This calls for being avoided under-five mortality. One may also rely on simpler logit somewhat parsimonious in the specifications. or probit models to analyze under-five mortality. In this case, the focus is on whether the child has survived, or not, as opposed to In addition to what is often done in the literature, this brief also how long the child has survived. Given the focus in this brief on assesses the potential reduction in under-five mortality that the contribution of early pregnancies and deliveries to under-five could arise from eliminating early pregnancies and deliveries, or, mortality, results from the probit regressions will be presented, said differently, the share of deaths for children under five that as they provide a simple way to provide those estimates. can be attributed to early childbirth according to the results. Finally, in term of interpretation, it is important to mention the Different specifications are estimated to assess the robustness risk of omitted variables bias, as noted in Box 3 of the brief. of the results to changes in the econometric models. Overall, the main results are robust to different specifications. For the baseline model, the independent variables are: (1) the age of the This brief was produced by a World Bank team as part of the Economic mother at the time of delivery by categories; (2) the child’s Impacts of Child Marriage study. The synthesis report under the study gender; (3) whether the child had siblings born at the same time was produced jointly with the International Center for Research on (multiple birth); (4) the birth order of the child and the child’s birth Women. The study benefitted from support from the Bill & Melinda Gates weight by categories; (5) the length of time between the child’s Foundation, the Children’s Investment Fund Foundation, and the Global birth and a previous birth for the mother; (6) whether the delivery Partnership for Education. Comments from colleagues and peer reviewers are gratefully acknowledged. The opinions expressed in this took place in a health facility; (7) the location of the child by brief are those of the authors only and need not reflect the views of the region and by urban-rural category; (8) the education of the World Bank, its Executive Directors, of the countries they represent. mother; (9) whether the household has access to an improved water source and improved sanitation; (10) the wealth quintile of the household; and finally (11) the ethnic group to which the child belongs. In a more extended model specification, two additional controls are added: (12) whether 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. 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