Knowledge Brief Health, Nutrition and Population Global Practice EARLY CHILDBIRTH AND UNDER-FIVE MALNUTRITION IN NIGER Adenike Onagoruwa and Quentin Wodon June 2017 Child Marriage Series with Education Global Practice KEY MESSAGES:  In Niger, more than 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 seven 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. development, cognitive skills, and productivity in adult life. Early childbearing is 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 Poor nutrition weakens children’s immune systems, will assist governments and others to make the case for putting them at a greater risk of falling sick from intervening to reduce the practice. preventable illnesses such as pneumonia and diarrhea. According to Horton et al. (2008), nearly one-fifth of What are the topics discussed in the series? The series under-five deaths in the world could be prevented with looks at the impacts of child marriage on health, population, optimal feeding. Research also suggests that poor education, employment, agency, and violence, among other nutrition at a young age may have irremediable outcomes. The welfare, budget, and non-monetary costs of child consequences for brain development, cognitive skills, and marriage are estimated. Legal/institutional aspects and options ultimately productivity in adult life. Unfortunately, a large to reduce the practice are also discussed. share of children in the developing world are What is the question asked in this brief? The question is: malnourished. The question considered in this brief is What is the impact at the margin of an early childbirth on the whether early childbirth (defined as a child being born of a probability of malnutrition (stunting) for children under-five years mother younger than 18), which in many countries is the of age? result of child marriage, contributes to under-five malnutrition in a significant way in Niger. The brief is part How is the question answered? Econometric analysis of of a series of similar standardized country-specific briefs Demographic and Health Survey data is used to estimate the 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 10 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 persistent exposure to malnutrition with potentially severe young mothers have a likelihood of stunting five long-term consequences throughout a person’s life (see percentage points higher than otherwise similar children box 2 on indicators used to measure malnutrition). The of older mothers. With the baseline specification, table 2 analysis is based on data from the 2012 Demographic suggests that deliveries at a young age increase the and Health Survey for Niger. Estimates suggest that likelihood of stunting for the children by 6.9 percentage 53.35 percent of children born of mothers younger than points in comparison to a delivery at 18 to 34 years of age 18 are stunted. The proportion is still high, but ten points (coefficient statistically significant at the ten percent level). lower at 43.06 percent for children born of mothers 18 to The difference in risk of stunting between mothers ages 34 years of age. The difference in stunting rate between 18-34 and mothers above 35 is not statistically significant. these two age groups is statistically significant. For children of mothers older than 35, the incidence of Deliveries at a young age may increase the likelihood of stunting was still slightly lower at 39.27 percent. stunting for the children by 6.9 percentage points 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 53.35 Marginal effects do not change much when additional Mother in 18-34 age bracket 43.06 controls are added (extended model). There is thus some Mother older than 35 39.27 evidence that after controlling for a wide range of other Source: Authors. variables, early childbirth may contribute to stunting, but prudence remains needed when interpreting these results Box 2: Measures of Malnutrition given the risk of omitted variable bias (see box 3). Three main measures of malnutrition are used in applied work. A Table 2: Impact of Early Childbirth on Stunting child is considered underweight if s/he has a weight more than Age at first marriage Baseline Extended two standard deviations below the reference median weight for model model the child’s age. A child is considered wasted if s/he has a weight Mother younger than 18 0.0691* 0.0700* to height ratio more than two standard deviations below the Mother in 18-34 age bracket Reference Reference median weight for height for the reference population. A child is Mother older than 35 -0.0251 -0.0195 considered stunted if s/he has a height more than two standard Source: Authors. deviations below the median reference height for that age. If a Levels of statistical significance: *** 1%, ** 5%, * 10%. child on any of these measures is below three standard deviations of the norm, s/he is considered as severely underweight, wasted, or stunted. Among the three measures, Box 3: Risk of Omitted Variable Bias stunting and wasting tend to be used the most. Stunting often results from persistent insufficient nutrient intake and infections. Early childbirth appears to be positively correlated with the risk It may lead to delayed motor development and poor cognitive of stunting after controlling for other factors that may also skills that can affect school performance as well as productivity contribute to stunting. This could indicate a causal effect. and earnings later in life. Wasting tends to result more from However, other variables correlated with both early childbirth acute food shortage or disease and may lead to death. For the and stunting not included in the analysis could be at the source purpose of this brief, given a separate brief of under-five of the correlation between early childbirth and stunting. Because mortality, stunting is the best measure to focus on. 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 of stunting. Controlling for other factors, early childbirth still increases the likelihood of stunting substantially. A number of results from the regression analysis not shown in table 2 are worth mentioning. The impact of The difference in the likelihood of stunting between wealth on the likelihood of stunting is not statistically children of young and older mothers does not necessarily significant, at least when measured through wealth imply a causal effect of the age at delivery, but it does quintiles. This is a bit surprising, but it could be due to the suggest that early childbirth may contribute to stunting. To fact that households in all four bottom quintiles are poor or check whether controlling for other factors early childbirth near poor in a country like Niger. Given that the incidence is indeed associated at the margin with higher under-five of stunting is so high, whether a household is being malnutrition, regression analysis is used (see the annex extremely poor, or simply poor, does not make much of a for details on the methodology). difference on the likelihood that children will be stunted. A number of other effects are also statistically significant, as discussed in the more detailed study on which the brief is Page 2 based. But one effect deserves discussion here: children order approximation, one may rely on the estimated direct from better educated mother are less likely to be stunted. effects of early childbirth on stunting when simulating the impact of the elimination of early childbirth on malnutrition As shown in table 3, the marginal impact of a mother in the country. Doing so does likely entail underestimation having a secondary education or better on the likelihood of the overall effects, but probably not by a wide margin. that her child will be stunted is statistically significant and large at nine to ten percentage points depending on the Simulations suggest that about one in 100 stunted model. This marginal effect is in comparison to mothers children is stunted directly due to early childbirth. with an education below the primary level. For primary schooling, the effect is small and not statistically The last step in the analysis consists in assessing the significant. The possibility of impacts through education potential impact of eliminating early childbirth on stunting. points more generally to the possibility of indirect effects This is done by predicting (i.e. simulating) the likelihood of early childbirth on stunting. Because early childbirth that children who were born of mothers younger than 18 may have an impact on other variables used as controls would have been stunted if they had been born of older in the regression, its overall effect on stunting, including mothers. In other words, we are considering the direct indirect effects through these other variables, may be effects of the age of the mother on stunting, shifting in the larger than the direct effect documented in table 2. For data deliveries by young mothers to deliveries at a later example, for some girls having a baby at a young age, age, and observing the difference that this makes for early childbirth may have reduced education attainment. stunting rates nationally. The simulations suggest that Early deliveries, by increasing the number of household without early deliveries, the share of children stunted members may also contribute to lower standards of living. could decrease by about 0.45 percentage point. This In terms of magnitude however, those indirect effects are corresponds (roughly) to the product of the marginal effect likely to be small in comparison to the direct effects in of early deliveries on stunting (0.07 in table 2) times the table 2. share of children born of mothers younger than 18 (seven percent of children). Given the rate of stunting nationally, While the effect of secondary education on stunting is one in 100 stunted children could be considered as large for women with a secondary education or better, the stunted due to the direct effect of early childbirth on the indirect effect of early childbirth on stunting through likelihood of stunting. This may appear low in comparison education is likely to be much smaller. This is because in to the total number of children who are stunted, but still Niger only a small share of girls with an early childbirth represents a large number of children. who have dropped out school due to the pregnancy would have remained in school long enough to complete Because only a small share of deliveries are by mothers secondary education if they had not become pregnant. younger than 18, only one in 100 stunted children can be Even if ten percent of the girls who became pregnant (or said to be stunted directly due to early childbirth. married) had completed their secondary education without the pregnancy (or marriage), the indirect effect of early Conclusion childbirth on stunting through education would be one tenth of the coefficients in table 3. This is not negligible, but much smaller than the effects reported in table 2. Early childbirth contributes to the risk of malnutrition for children, directly and indirectly. This brief has provided estimates of the direct impact of early childbirth on Early childbirth may affect malnutrition through lower stunting in Niger using the latest DHS survey. More than education attainment for mothers or lower economic four in ten children under the age of five are stunted. For status, but these effects are likely to be smaller. children born of mothers younger than 18, the risk of stunting is higher by ten percentage points. Controlling for Table 3: Impact of the Mother’s Education on Stunting socio-economic and other characteristics, being born of a Age at first marriage Baseline Extended mother younger than 18 appears to increase the model model likelihood of stunting by seven percentage points versus No education or below primary Reference Reference children born of older mothers. Given the share of Primary education -0.00706 -0.00535 children born of mothers younger than 18, nationally for Secondary education or higher -0.0965** -0.0875* every 100 stunted children, at least one could be stunted Source: Authors. directly because of early childbirth. This may appear low, Levels of statistical significance: *** 1%, ** 5%, * 10%. but still represents a large number of children. As to the indirect effect of early childbirth on stunting References through household welfare (measured by wealth quintiles), it does not need to be considered since the Fall, C. H., et al., 2015, Association between maternal age at regression coefficients for the wealth quintiles are not childbirth and child and adult outcomes in the offspring: a statistically significant. Overall, this suggests that as a first prospective study in five low-income and middle-income Page 3 HNPGP Knowledge Brief  countries (COHORTS collaboration), Lancet Glob Health affect the health of their children. This brief estimates the direct 3(7):e366-77. impact of early childbirth on under-five malnutrition. Finlay. J. E., E. Özaltin, and D. Canning, 2011, The association In addition, the brief provides an assessment of the extent to of maternal age with infant mortality, child anthropometric failure, which under-five malnutrition would be reduced if early diarrhoea and anaemia for first births: evidence from 55 low- and pregnancies/deliveries were eliminated. In order to measure the middle-income countries, BMJ 1:e000226. potential impact of early childbirth at the margin on stunting for children under the age of five, regression analysis is used. In the Horton, S., H. Alderman, and J. Rivera. 2008. “Copenhagen more detailed paper on which this brief is based, both tobit Consensus 2008 Challenge Paper: Hunger and Malnutrition.” regressions (to measure the degree of stunting among children http://www.copenhagenconsensus.com. who are stunted) and probit regressions (to measure the likelihood of stunting) are provided. In this brief, due to space République du Niger, 2013, Enquête Démographique et de constraints and because of the interest in the share of stunting Santé et à Indicateurs Multiples (EDSN-MICS IV) 2012, Institut that could be attributed to early childbirth, the focus is on National de la Statistique et MEASURE DHS, Rockville, MD: ICF reporting results from probit regressions. In those regressions, International. the dependent variable is whether a child is stunted or not. Annex: Methodological Note Different specifications are estimated to assess the robustness of the results to the choice of models. Overall, the results are There is an existing literature on the relationships between early fairly robust to different specifications. For the baseline model, childbirth, child marriage, and the risks of under-five malnutrition the independent variables are the following: (1) the age of the (e.g., Fall et al., 2015, and Finlay et al. 2011). This literature mother at the time of delivery by categories; (2) the child’s age suggests that children born of young mothers are at higher risk and gender; (3) whether the child had siblings born at the same of malnutrition. How much higher in the case of Niger is the time (multiple birth); (4) the birth order of the child and the child’s question to be answered. To answer this question, this brief birth weight by categories; (5) the length of time between the focuses on stunting as the measure that tends to best capture child’s birth and a previous birth for the mother; (6) whether the persistent exposure to malnutrition with likely long term negative child has received recommended immunizations; (7) whether the consequences for children. delivery took place in a health facility and was attended by skilled personnel; (8) the mother’s height and education level, as There is no doubt that children born to very young mothers are well as whether she works and the type of work involved; (9) the more likely to be malnourished than other children, but this might father’s occupation and his level of education; (10) the location not specifically be due to the fact that the mothers are young. of the child by region and by urban-rural category; (11) whether Girls who have children before the age of 18 tend to be poorer. the household has access to an improved water source and This implies that their children are at higher risk of inadequate improved sanitation; (12) whether the household has more than nutritional intake. Early pregnancies are more common in areas two children under-five; and finally (13) the wealth quintile of the where access to healthcare is limited to prevent or treat household. In the extended model, additional controls are malnutrition. Young girls also often suffer from a lack of agency added: (14) whether the household practices polygyny; (15) and decision-making power in the household, which may reduce whether the distance to health facility is a major problem for the their ability to seek care for their children when needed. Girls household; (16) the age gap between the spouses; (17) who give birth early are likely to have dropped out of school due indicators of decision-making power for the mother; (19) to pregnancy or marriage, which may also affects the nutritional tolerance towards wife beating; and (20) whether the mother is status of their children due to lack of education or knowledge on able to get permission to access healthcare. how to best take care of young children. This brief was produced by a World Bank team as part of the Economic These risk factors correlated with early childbirth do not Impacts of Child Marriage study. The synthesis report under the study necessarily imply that early pregnancies by themselves was produced jointly with the International Center for Research on contribute in a direct way to child malnutrition. Controlling for Women. The study benefitted from support from the Bill & Melinda Gates other factors, it could be that early childbirth does not lead to a Foundation, the Children’s Investment Fund Foundation, and the Global higher risk of malnutrition for children. But it could also be that Partnership for Education. Comments from colleagues and peer there is a direct causal link between early childbirth and child reviewers are gratefully acknowledged. The opinions expressed in this brief are those of the authors only and need not reflect the views of the malnutrition, for example if some young mothers giving birth are World Bank, its Executive Directors, of the countries they represent. not yet be ready physiologically to give birth, which could in turn 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