Knowledge Brief Health, Nutrition and Population Global Practice BASIC PROFILE OF EARLY CHILDBIRTH IN NEPAL Chata Malé and Quentin Wodon March 2016 Child Marriage Series with Education Global Practice KEY MESSAGES:  Measures of early childbirth are high in Nepal. The share of women ages 18-22 who had a child before 18 is 17.4 percent and it has decreased only slightly over time. The share of girls who had a child before the age of 15, at one percent, has also decreased.  Early childbirth is associated with lower wealth, lower education levels, and employment without cash earnings. 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 Nepal. 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  One in six of 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 Nepal for 2011, the latest in capturing how early girls have children (see the annex). DHS available. Table 1 provides basic statistics on the The headcount (H) measures the share of girls with an 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). One in six women have their first child before 18, and one percent do so before 15. There is Early childbirths have decreased slightly over time. a decrease in the mean age at first birth between the 18- 49 sample and the 18-22 sample. This is in large part Table 3 provides trends over time in the measures of because many women ages 18 to 22 did not yet has a early childbirth inspired by the poverty literature. Consider birth. first the age group 18-22. In that age group, on in six Table 1: Age at First Birth for Women (%) women had their first child before the age of 18 (17.4 18-22 years 18-49 years percent for the 18-22 age group). The early childbirth gap No live Birth 58.8 19.6 (CBG) is at 1.7 percent and the squared gap ( SG) at 0.2 18 or Above 23.7 59.0 percent for that group. By estimating the same measures Below 12 0.1 on older groups, the table provides the trend in early 12 0.1 0.1 childbirth over time. There has only been a slight 13 0.2 0.3 decrease over time in early childbirth, at least comparing 14 0.6 1.4 the youngest with the oldest age groups. In other words, 15 2.9 3.4 in contrast to child marriage, early childbirth has been 16 5.3 6.6 reduced only marginally over time. The reduction is 17 8.5 9.5 however stronger proportionately when considering very Total 100.0 100.0 Mean age at first birth 17.9 19.6 early childbirth before the age of 152. Source: Authors’ estimation. Table 3: Trend in Early childbirth (%) Most early childbirths take place after marriage. 18 years 15 years H CMG SG H CMG SG All 18-49 years 21.3 2.27 0.31 1.8 0.17 0.02 In Nepal, there is a strong relationship between the age at Age group first birth and the age at first marriage as communities do 18-22 years 17.4 1.74 0.22 0.9 0.08 0.01 not look favorably at births out of wedlock. Table 2 23-30 years 23.2 2.45 0.33 1.9 0.16 0.01 displays the shares of girls with an early childbirth 31-40 years 23.7 2.57 0.37 2.5 0.22 0.03 according to four categories in terms of the timing (or 41-49 years 19.5 2.16 0.32 1.9 0.20 0.03 absence) of marriage among women ages 18-22. Most Source: Authors’ estimation. Values rounding to 0.0 not shown. early childbirths take place after marriage, hence delaying the age at marriage is essential to avoid early childbirth. The incidence of early childbirth in Nepal in 2011 was slightly lower than that observed 25 years ago. There has Table 2: Marriage and Early Childbirth, Age 18-22 (%) been a decrease over time in how early girls have Share children. Early childbirth without marriage 0.0 Early childbirth before marriage 1.4 Early childbirth in the same year as marriage 7.8 Girls are more likely to have children early if they live Early childbirth at least one year after marriage 90.8 in rural areas and are from poorer backgrounds. Total 100.0 Source: Authors’ estimation. As expected, early childbirth is much more prevalent in rural than in urban areas. There are also large differences between regions, with the lowest measures observed in the Hills, and the highest measures observed (according to the headcount index with the 18 years threshold) in the 1 Terai. The ranking of the regions in terms of the measures 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  obtained with the 15 and 18 years thresholds tends to be as the ability to pursue one’s education may help delay similar, although very early childbirth is less frequent in the age at marriage and thereby the age at first birth. As the Mountains. seen in table 6, early childbirth measures are strongly correlated with education levels. The same is observed Table 4: Early childbirth by Location, Age 18-22 (%) when considering literacy where three categories are 18 years 15 years considered: the woman cannot read at all, can read part H CMG SG H CMG SG of a sentence, or can read a full sentence. All 18-22 years 17.4 1.74 0.22 0.9 0.08 0.01 Region Table 6: Early childbirth by Education Level and Mountain 18.0 1.63 0.18 - - - Literacy Status, Age 18-22 (%) Hill 16.3 1.60 0.20 0.6 0.07 0.01 18 years 15 years Terai 18.2 1.86 0.24 1.1 0.10 0.01 Residence H CMG SG H CMG SG Urban 9.1 0.94 0.12 0.2 0.02 - All 18-22 years 17.4 1.74 0.22 0.9 0.08 0.01 Rural 18.9 1.88 0.24 1.0 0.09 0.01 Education Source: Authors’ estimation. Values rounding to 0.0 not shown. No education 35.3 3.59 0.48 2.4 0.21 0.02 Primary, some 29.8 3.37 0.47 1.1 0.13 0.02 Primary, compl. 29.2 3.20 0.47 3.9 0.36 0.04 Rural girls are much more likely to have children early Secondary, some 16.9 1.46 0.15 0.1 0.01 - than urban girls. Girls from the bottom four quintiles of Secondary, compl. 3.5 0.29 0.03 - - - wealth are also more likely to have children early. The Higher 0.4 0.03 - - - - relationship between early childbirth, literacy, and Literacy education attainment is strong. Early childbirth measures Cannot read 33.7 3.42 0.46 2.1 0.20 0.02 Limited ability 34.2 3.51 0.44 1.0 0.06 - are higher among women who work. Full sentence 12.4 1.22 0.15 0.5 0.05 0.01 Source: Authors’ estimation. Values rounding to 0.0 not shown. Household welfare is measured through a wealth index with households categorized according to five quintiles of Table 7 provides data on labor force participation. One wealth. Women who had a birth tend to be married, hence would expect early childbirth to reduce women’s labor the level of wealth is that of the household in which the force participation, for example through higher fertility. But women married, not that of the household or origin. Yet if early childbirth is associated with poverty, women may the quintile of wealth after marriage and first birth may not leave little choice but to work. Other effects could also be be very different from that of the household of origin. On at work. In Nepal, early childbirth measures are slightly the other hand, since early childbirth measures are based higher among women who work. However, the type of on young women ages 18-22, their level of assets may be work associated most closely with early childbirth is work lower than would be the case later in life. In any case, the with payment in kind, which may be work with low measures of early childbirth differ by quintile, but it is only productivity. with the top quintile that early childbirth is much less prevalent. Table 7: Early childbirth by Labor Force Participation Status, Age 18-22 (%) Table 5: Early childbirth by Quintile, Age 18-22 (%) 18 years 15 years 18 years 15 years H CMG SG H CMG SG H CMG SG H CMG SG All 18-22 years 17.4 1.7 0.22 0.9 0.08 0.01 All 18-22 years 17.4 1.7 0.2 0.9 0.08 0.01 Working Wealth quintiles No 16.6 1.6 0.21 0.6 0.07 0.01 Poorest 25.1 2.5 0.3 0.7 0.06 0.01 Yes 17.9 1.8 0.23 1.0 0.08 0.01 Poorer 24.2 2.4 0.3 1.3 0.12 0.01 Type of work Middle 20.9 1.9 0.2 0.9 0.06 - Not paid 19.5 1.9 0.23 0.8 0.07 0.01 Richer 14.3 1.5 0.2 0.9 0.09 0.01 Cash only 12.1 1.3 0.18 1.2 0.12 0.01 Richest 5.2 0.6 0.1 0.4 0.07 0.01 Cash and in-kind 22.3 2.8 0.41 - - - Source: Authors’ estimation. Values rounding to 0.0 not shown. In-kind only 21.7 2.8 0.42 3.0 0.20 0.01 Source: Authors’ estimation. Values rounding to 0.0 not shown. Early childbirth is associated with lower education attainment, lower likelihood of literacy and higher labor force participation. Table 6 provides data on early childbirth by level of education of the women, as well as literacy. Early childbirth affects education attainment negatively, because girls often drop out of school when they have their first child. The causality goes the other way as well, Page 3 HNPGP Knowledge Brief  Conclusion child early, but also the mean number of years below 18 (or 15) at which girls had their first child. This matters because even if This brief has provided a basic profile of early childbirth in the share of girls who have their first child early does not Nepal. Measures of early childbirth are high. The share of change, there may still be improvements in the early childbirth gap if girls who have their first child early have that child a little women ages 18-22 who had their first child before 18 is less early. 17.4 percent and it has only marginally decreased over time. The share of women with their first child before 15 is Finally, the squared early childbirth gap measures the “severity” much lower at 0.9 percent. Early childbirth is associated of early childbirth. While the early childbirth gap takes into with lower wealth and lower education levels, and account the average number of years of early marriage for girls employment without cash earnings. These are however who have their first child early, the squared gap takes into only correlations, not necessarily causal effects. Other account the square of that number, thereby putting more briefs in this series look at potential causal effects. emphasis on girls who have their first child very early. Together the three measures provide a better diagnostic of early childbirth than the headcount index alone. The measures also have References attractive properties that are beyond the scope of this brief. Foster, J., J. Greer, and E. Thorbecke, 1984, A Class of The headcount index, early childbirth gap, and squared gap are Decomposable Poverty Measures, Econometrica 52: 761–776. the first three measures of the so-called FGT class (Foster et al., 2014). Denote by q the number of girls who have their first child Nguyen, M. C., and Q. Wodon, 2012, Measuring Child Marriage, early and by n the number of girls in the overall population. Economics Bulletin, 32(1): 398-411. 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 Annex: Methodological Note lower age threshold such as 15 can also be used to measure extremely early childbirth). The general formula for the FGT While many studies have discussed trends in child marriage, class of measures depends on a parameter α which takes a less work has been done on trends in early childbirth. When value of zero for the headcount, one for the early childbirth gap, conducted, measurement of early childbirth (or early pregnancy) and two for the squared gap in: has focused on one simple statistic such as the share of girls  1 q  z  yi  P    who have a live birth before the age of 18 or 15. Such statistics are useful, but they do not capture well the distribution of the age at first birth in the form of aggregate statistics that tell us n i1  z   about the depth and severity of the problem. Basic statistics on the share of girls having an early childbirth also do not facilitate testing for the robustness of comparisons of trends in early This brief was produced as part of the Economic Impacts of Child childbirth between countries, between groups within countries, Marriage study, a joint project of the International Center for Research or between time periods. on Women (ICRW) and the World Bank, which is supported by the Bill & Melinda Gates Foundation and the Children’s Investment Fund Following the approach used by Ngyuen and Wodon (2012) for Foundation (CIFF). More details on the research can be found at the project’s website: www.costsofchildmarriage.org. Partial funding for the child marriage, this brief and its companion paper (available on work related to child marriage and education, labor force participation, request) rely on methods from the poverty literature to measure earnings, and program responses has been provided by the Global early childbirth. Three measures are used: the incidence of early Partnership for Education. Comments from Jeff Edmeades and Michele childbirth or headcount index, the early childbirth gap, and the Gragnolati are gratefully acknowledged. The opinions expressed in this squared early childbirth gap. The headcount index is simply the brief are those of the authors only and need not reflect the views of the share of the girls who have their first live birth before the age of World Bank, its Executive Directors, of the countries they represent. 18. The headcount index can be computed for other age thresholds, such as 15 years of age. The early childbirth gap represents the “depth” of early childbirth. It takes into account not only the share of girls who had their first 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