Knowledge Brief Health, Nutrition and Population Global Practice EARLY CHILDBIRTH AND UNDER FIVE MALNUTRITION IN MALAWI Adenike Onagoruwa and Quentin Wodon June 2017 Child Marriage Series with Education Global Practice KEY MESSAGES:  In Malawi, 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 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. 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. Early development, cognitive skills, and productivity in adult life. 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 development outcomes. Demonstrating these impacts will assist Poor nutrition weakens children’s immune systems, putting governments and others to make the case for intervening to them at a greater risk of falling sick from preventable reduce the practice. illnesses such as pneumonia and diarrhea. According to Horton et al. (2008), nearly one-fifth of under-five deaths in What are the topics discussed in the series? The series looks the world could be prevented with optimal feeding. 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 practice are also discussed. adult life. Unfortunately, a large share of children in the developing world are malnourished. The question What is the question asked in this brief? The question is: What considered in this brief is whether early childbirth (defined is the impact at the margin of an early childbirth on the probability as a child being born of a mother younger than 18), which of malnutrition (stunting) for children under five years of age? in many countries is the result of child marriage, contributes to under five malnutrition in a significant way in Malawi. The How is the question answered? Econometric analysis of brief is part of a series of similar standardized country- Demographic and Health Survey data is used to estimate the specific briefs 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 in Malawi statistically significant coefficient of 0.05 for a mother are four percentage points less likely to be stunted younger than 18 would indicate that children of very young than if the mother is between 18 and 34 years of age. mothers have a likelihood of stunting five percentage points higher than otherwise similar children of older mothers. The focus in this brief is on stunting as a measure of With the baseline specification, table 2 indicates that persistent exposure to malnutrition with potentially severe deliveries at a young age do not significantly increase the long-term consequences throughout a person’s life (see likelihood of stunting for the children in comparison to a box 2 on indicators used to measure malnutrition). The delivery at 18 to 34 years of age (in Malawi). The difference analysis is based on data from the 2010 Demographic and in risk of stunting between mothers ages 18-34 and Health Survey for Malawi. Estimates suggest that 43.86 mothers above 35 is also not statistically significant. percent of children born of mothers younger than 18 are stunted. The proportion is slightly higher at 47.62 percent In Malawi, delivery at a young age does not increase the for children born of mothers 18 to 34 years of age. The likelihood of stunting for the child in comparison to a difference in stunting rate between these two age groups is delivery at 18 to 34 years of age. not statistically significant. For children of mothers older than 35, the incidence of stunting was 45.13 percent. Marginal effects do not change much when additional Table 1: Incidence of Stunting by Age of the Mother controls are added (extended model). There is thus some Age of the mother Stunting (%) evidence that in the case of Malawi, after controlling for a Mother younger than 18 43.86 wide range of other variables, early childbirth may not Mother in 18-34 age bracket 47.62 contribute to stunting, but prudence remains needed when Mother older than 35 45.13 interpreting these results given the risk of omitted variable Source: Authors. bias (see box 3). Box 2: Measures of Malnutrition Table 2: Impact of Early Childbirth on Stunting Age at first marriage Baseline Extended Three main measures of malnutrition are used in applied work. A model model child is considered underweight if s/he has a weight more than Mother younger than 18 -0.0442 -0.0415 two standard deviations below the reference median weight for Mother in 18-34 age bracket Reference Reference the child’s age. A child is considered wasted if s/he has a weight Mother older than 35 -0.0265 -0.0128 to height ratio more than two standard deviations below the Source: Authors. median weight for height for the reference population. A child is Levels of statistical significance: *** 1%, ** 5%, * 10%. considered stunted if s/he has a height more than two standard deviations below the median reference height for that age. If a Box 3: Risk of Omitted Variable Bias child on any of these measures is below three standard deviations of the norm, s/he is considered as severely underweight, wasted, In many countries, although not in Malawi, early childbirth or stunted. Among the three measures, stunting and wasting tend appears to be positively correlated with the risk of stunting after to be used the most. Stunting often results from persistent controlling for other factors that may also contribute to stunting. insufficient nutrient intake and infections. It may lead to delayed This could indicate a causal effect. However, other variables motor development and poor cognitive skills that can affect school correlated with both early childbirth and stunting not included in performance as well as productivity and earnings later in life. the analysis could be at the source of the correlation between Wasting tends to result more from acute food shortage or disease early childbirth and stunting. Because of the risk of omitted and may lead to death. For the purpose of this brief, given a variable bias, the results cannot be considered as fully conclusive separate brief of under five mortality, stunting is the best measure regarding a causal impact of early childbirth on the risk of stunting. to focus on. A number of results from the regression analysis not shown Controlling for other factors, early childbirth does not in table 2 are worth mentioning. The impact of wealth on increase the likelihood of stunting substantially. the likelihood of stunting is statistically significant, with children from wealthier households tending to be less The difference in the likelihood of stunting between children stunted. For example, compared to children in the poorest of young and older mothers does not necessarily imply a 20% of households, those from the second, third and fourth causal effect of the age at delivery. To check whether quintiles have a likelihood of stunting ranging from 7-8 controlling for other factors early childbirth is associated at percentage points lower. Children in the highest quintile the margin with higher under five malnutrition, regression (the richest 20% of households) have a likelihood of analysis is used (see the annex for details on the stunting 19 percentage points lower. methodology). As shown in table 3, the marginal impact of a mother having Table 2 provides key results with baseline and extended a secondary education or better on the likelihood that her models. The interpretation of the coefficients is in terms of child will be stunted is not statistically significant, which is marginal impacts in percentage terms. For example, a somewhat surprising. Page 2 Conclusion Note though more generally that the inclusion of education as a control points to the possibility of indirect effects of Early childbirth may contribute to the risk of malnutrition for early childbirth on stunting. Because early childbirth may children, directly and indirectly. This brief has provided have an impact on other variables used as controls in the estimates of the direct impact of early childbirth on stunting regression, its overall effect on stunting, including indirect in Malawi using the latest DHS survey. More than four in effects through these other variables, may be larger than ten children under the age of five are stunted. Controlling the (non-significant) direct effect documented in table 2. for socio-economic and other characteristics, being born of For example, for some girls having a baby at a young age, a mother younger than 18 does not have a statistically early childbirth could have reduced education attainment, significant effect on the likelihood of stunting as compared which could lead to a higher risk of stunting (although not to otherwise similar children born of older mothers. This, in Malawi according to the regression results). In addition, together with small indirect effects of early childbirth early deliveries, by increasing the number of household through education in Malawi, suggests that few children are members may also contribute to lower standards of living. stunted directly or indirectly because of an early childbirth, In Malawi, as mentioned earlier, the regression results even though some may be. suggest that the level of welfare as measured through wealth quintiles have an effect on stunting. References Early childbirth may affect under five malnutrition through Fall, C. H., et al., 2015, Association between maternal age at childbirth and child and adult outcomes in the offspring: a lower education attainment for mothers or lower socio- prospective study in five low-income and middle-income countries economic status. (COHORTS collaboration), Lancet Glob Health 3(7):e366-77. Table 3: Impact of the Mother’s Education on Stunting Finlay. J. E., E. Özaltin, and D. Canning, 2011, The association Age at first marriage Baseline Extended of maternal age with infant mortality, child anthropometric failure, model model diarrhoea and anaemia for first births: evidence from 55 low- and No education or below primary Reference Reference middle-income countries, BMJ 1:e000226. Primary education -0.0450 -0.0413 Secondary education or higher -0.0703 -0.0748 Horton, S., H. Alderman, and J. Rivera. 2008. “Copenhagen Source: Authors. Consensus 2008 Challenge Paper: Hunger and Malnutrition.” Levels of statistical significance: *** 1%, ** 5%, * 10%. http://www.copenhagenconsensus.com. National Statistical Office (NSO) and ICF Macro (2011). Malawi Simulations suggest that very few children under five Demographic and Health Survey 2010. Zomba, Malawi, and are stunted directly due to early childbirth. Calverton, Maryland, USA: NSO and ICF Macro. 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 likelihood that children who were born of mothers younger than 18 would have been stunted if they had been born of older mothers. In other words, we are considering the direct effects of the age of the mother on stunting, shifting in the data deliveries by young mothers to deliveries at a later age, and observing the difference that this makes for stunting rates nationally. In the case of Malawi, because the effect of early childbirth on stunting is not statistically significant, direct effects are not (statistically speaking) present. Because only a small share of deliveries are by mothers younger than 18, very few stunted children can be said to be stunted directly due to early childbirth. Page 3 HNPGP Knowledge Brief  Annex: Methodological Note In this brief, due to space constraints and because of the interest There is an existing literature on the relationships between early in the share of stunting that could be attributed to early childbirth, childbirth, child marriage, and the risks of under five malnutrition the focus is on reporting results from probit regressions. In those (e.g., Fall et al., 2015, and Finlay et al. 2011). This literature regressions, the dependent variable is whether a child is stunted suggests that children born of young mothers are at higher risk of or not. malnutrition. How much higher in the case of Niger is the question to be answered. To answer this question, this brief focuses on Different specifications are estimated to assess the robustness of stunting as the measure that tends to best capture persistent the results to the choice of models. Overall, the results are fairly exposure to malnutrition with likely long term negative robust to different specifications. For the baseline model, the consequences for children. independent variables are the following: (1) the age of the mother at the time of delivery by categories; (2) the child’s age and There is no doubt that children born to very young mothers are gender; (3) whether the child had siblings born at the same time more likely to be malnourished than other children, but this might (multiple birth); (4) the birth order of the child and the child’s birth not specifically be due to the fact that the mothers are young. Girls weight by categories; (5) the length of time between the child’s who have children before the age of 18 tend to be poorer. This birth and a previous birth for the mother; (6) whether the child has implies that their children are at higher risk of inadequate received recommended immunizations; (7) whether the delivery nutritional intake. Early pregnancies are more common in areas took place in a health facility and was attended by skilled where access to healthcare is limited to prevent or treat personnel; (8) the mother’s height and education level, as well as malnutrition. Young girls also often suffer from a lack of agency whether she works and the type of work involved; (9) the father’s and decision-making power in the household, which may reduce occupation and his level of education; (10) the location of the child their ability to seek care for their children when needed. Girls who by region and by urban-rural category; (11) whether the give birth early are likely to have dropped out of school due to household has access to an improved water source and improved pregnancy or marriage, which may also affects the nutritional sanitation; (12) whether the household has more than two status of their children due to lack of education or knowledge on children under five; and finally (13) the wealth quintile of the how to best take care of young children. household. These risk factors correlated with early childbirth do not In the extended model, additional controls are added: (14) necessarily imply that early pregnancies by themselves contribute whether the household practices polygyny; (15) whether the in a direct way to child malnutrition. Controlling for other factors, distance to health facility is a major problem for the household; it could be that early childbirth does not lead to a higher risk of (16) the age gap between the spouses; (17) indicators of malnutrition for children. But it could also be that there is a direct decision-making power for the mother; (19) tolerance towards causal link between early childbirth and child malnutrition, for wife beating; and (20) whether the mother is able to get example if some young mothers giving birth are not yet be ready permission to access healthcare. physiologically to give birth, which could in turn affect the health of their children. This brief estimates the direct impact of early This brief was produced by a World Bank team as part of the Economic childbirth on under five malnutrition. Impacts of Child Marriage study. The synthesis report under the study was produced jointly with the International Center for Research on Women. In addition, the brief provides an assessment of the extent to The study benefitted from support from the Bill & Melinda Gates which under five malnutrition would be reduced if early Foundation, the Children’s Investment Fund Foundation, and the Global pregnancies/deliveries were eliminated. In order to measure the Partnership for Education. Comments from colleagues and peer potential impact of early childbirth at the margin on stunting for reviewers are gratefully acknowledged. The opinions expressed in this 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