Knowledge Brief Health, Nutrition and Population Global Practice EARLY CHILDBIRTH AND UNDER-FIVE MORTALITY IN BURKINA FASO Adenike Onagoruwa and Quentin Wodon June 2017 Child Marriage Series with Education Global Practice KEY MESSAGES:  In Burkina Faso, about one in eight children die before the age of five; for children born of mothers younger than 18, the risk 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 six 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 further reducing access to care. In addition, some girls marriage are estimated. Legal/institutional aspects and options 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 Burkina Faso. impact of early childbirth on under-five mortality. Page 1 HNPGP Knowledge Brief  Statistically, children from young mothers are five young age increase the likelihood of under-five mortality percentage points more likely to die before five. for the children by 6.0 percentage points in comparison to a delivery at 18 to 34 years of age (coefficient statistically The analysis is based on data from the 2010 significant at the one percent level). The difference in risk Demographic and Health Survey for Burkina Faso. of under-five mortality between mothers ages 18-34 and According to the survey, the under-five mortality remains mothers above 35 is not statistically significant. high with one in eight children dying before the age of five (129 ‰). But there has also been some progress over Deliveries at a young age increase the likelihood of under- time, as the rate decreased from 177 ‰ to 129 ‰ in the five mortality for the children by 6.0 percentage points in 15 years period preceding the 2010 survey (Institut comparison to a delivery at 18 to 34 years of age. National de la Statistique et de la Démographie (INSD) et ICF International, 2012). Marginal effects do not change much when additional controls are used (extended model). There is thus some In this brief we focus on whether all children identified in evidence that in the case of Burkina Faso, after controlling the survey have died or not before reaching five years of age, and the factors that affect that outcome. This implies for a wide range of other variables, early childbirth may relying on statistics computed in a different way from the contribute to under-five mortality, but prudence remains needed when interpreting the results given the risk of official under-five mortality rate, but the idea and orders of omitted variable bias (box 2). magnitude are similar (to avoid a risk of confusion, we will use below the term “under-five mortality” but not the term Table 2: Impact of Early Childbirth on Under-five “under-five mortality rate”). As shown in table 1, 13.94 Mortality percent of children born of mothers younger than 18 die Age at first marriage Baseline Extended before reaching five years of age. The proportion, which model model we refer to as under-five mortality, is 8.64 percent for Mother younger than 18 0.0597*** 0.0584*** children born of mothers 18 to 34 years of age. The Mother in 18-34 age bracket Reference Reference difference in under-five mortality between the two age Mother older than 35 -0.00886 -0.0108 groups is statistically significant. For children of older Source: Authors. mothers (35 and older), the under-five mortality is at 8.78 Levels of statistical significance: *** 1%, ** 5%, * 10%. percent. Box 2: Risk of Omitted Variable Bias Table 1: Under-five Mortality by Age of the Mother Age of the mother Under-five Mortality In many countries, early childbirth appears to be positively (‰) correlated with the risk of under-five mortality after controlling for Mother younger than 18 13.94 other factors that may also contribute to mortality. This could Mother in 18-34 age bracket 8.64 indicate a causal effect. However, other variables correlated with Mother older than 35 8.78 both early childbirth and under-five mortality not included in the Source: Authors. analysis could be at the source of the correlation between early childbirth and under-five mortality. Because of the risk of omitted Controlling for other factors, early childbirth variable bias, the results cannot be considered as fully increases the likelihood of under-five mortality. conclusive regarding a causal effect of early childbirth on under- five mortality. The difference in under-five mortality between children of young and older mothers does not necessarily imply a A number of results from the regression analysis not causal effect of the age at delivery, but it does suggest shown in table 2 are worth mentioning. The impact of the that early childbirth may contribute to under-five mortality. education of the mother on the likelihood of under-five To check whether controlling for other factors early mortality is not statistically significant. Similarly, the childbirth is indeed associated at the margin with higher impact of wealth on the likelihood of under-five mortality is under-five mortality, regression analysis is used (see the not statistically significant, at least when measured annex for details on the methodology). through the wealth quintiles. This is a bit surprising, but it could be due to the fact that households in all four bottom Table 2 provides key results with baseline and extended quintiles are poor or near poor in a country like Burkina models. The interpretation of the coefficients is in terms of Faso, and whether a household is extremely poor or marginal impacts in percentage terms. For example, a simply poor may not make much of a difference on the statistically significant coefficient of 0.05 for a mother likelihood that the child may die. A few other effects are younger than 18 would indicate that children of very also statistically significant, as discussed in the more young mothers have a likelihood of under-five mortality detailed study on which the brief is based. five percentage points higher than children of older mothers, controlling for other characteristics. With the The evidence in table 2 suggests that early childbirth baseline specification, table 2 suggests that deliveries at a increases the likelihood of under-five mortality. This is a Page 2 HNPGP Knowledge Brief  direct impact controlling for other independent variables included in the models. Could early pregnancy and Conclusion delivery also have an indirect impact on under-five mortality through the effect of early pregnancy or delivery Early pregnancy and delivery may contribute to the risk of on some of the other variables that are used as controls in under-five mortality for children, directly, or indirectly. This the regression? For example, for some of the girls brief has provided estimates of the direct impact of early delivering a baby at a young age, early pregnancy has a childbirth on under-five mortality in Burkina Faso using the negative effect on education enrollment and attainment. latest DHS survey. About one in eight children under the Early deliveries, by increasing the number of children that age of five die; but for children born of mothers younger women have, may also contribute to lower labor force than 18, the risk of under-five mortality is higher by 6.0 participation for women and thereby lower household percentage points than the risk for children of older wealth. There could be such effects, but in terms of mothers. magnitude, indirect effects are likely to be small in comparison to the direct effects in table 2. This is simply Because only a small share of deliveries are by mothers because in the full regression estimates for the correlates younger than 18, only three in 100 children deaths before of under-five mortality (not shown here), the effects of the five can be said to be directly due to early childbirth. mother’s education and the wealth status of the households on mortality are not statistically significant, at Controlling for socio-economic and other characteristics, least in the case of Burkina Faso. being born of a mother younger than 18 increases the likelihood of under-five mortality for children by six Early childbirth may also affect under-five mortality percentage points, as compared to otherwise similar indirectly, for example through lower education attainment children born of older mothers. Given the share of for mothers, but these effects are likely to be smaller. children born of young mothers, nationally for every 100 children who die before the age of five, three may die Simulations suggest that about three in 100 deaths directly because of an early childbirth. This may appear for children under five are directly due to early low, but still represents a large number of children. childbirth. References The last step in the analysis of the impact of early pregnancy and delivery on under-five mortality consists in Bicego, G., & Ahmad, O. (1996). Infant and child mortality, assessing the potential reduction in under-five mortality Demographic and health surveys comparative studies No. that could arise from eliminating early pregnancies and 20. Calverton (Maryland): Macro International Inc . deliveries. This can be done by predicting (i.e. simulating) Institut National de la Statistique et de la Démographie (INSD) et the likelihood that children who were born of mothers ICF International, 2012. Enquête Démographique et de Santé et younger than 18 would have remained alive if they had à Indicateurs Multiples du Burkina Faso 2010 . Calverton, been born of older mothers. In other words, we are Maryland, USA : INSD et ICF International. considering the direct effects of the age of the mother on under-five mortality, shifting in the data deliveries by Nasrullah, M., Zakar, R., Zakar, M. Z., & Krämer, A. (2014). Girl- young mothers to deliveries at a later age, and observing child marriage and its association with morbidity and mortality of the difference that this makes for under-five mortality children under 5 years of age in a nationally-representative nationally. sample of Pakistan. The Journal of pediatrics,164(3), 639-646. Prakash, R., Singh, A., Pathak, P. K., & Parasuraman, S. The simulations suggest that without early pregnancies (2011). Early marriage, poor reproductive health status of and deliveries, the share of children dying before five mother and child well-being in India.Journal of family planning could decrease by 0.30 percentage point. This essentially and reproductive health care, jfprhc80. corresponds to the product of the marginal effect of early deliveries on under-five mortality (0.0597 in table 2) times Raj, A., Saggurti, N., Winter, M., Labonte, A., Decker, M. R., the share of children born of mothers younger than 18 Balaiah, D., & Silverman, J. G. (2010). The effect of maternal (five percent of children). Given the estimate of under-five child marriage on morbidity and mortality of children under 5 in mortality nationally, three in every 100 children dying India: cross sectional study of a nationally representative before the age of five can be considered as dying due to sample. BMJ, 340. the direct effect of early pregnancies and deliveries on the Raj, A., & Boehmer, U. (2013). Girl child marriage and its likelihood of under-five mortality. This may appear association with national rates of HIV, maternal health, and relatively low in comparison to the total number of children infant mortality across 97 countries.Violence against who die, but still represents a large number of children. women, 19(4), 536-551. Raj, A., McDougal, L., & Rusch, M. L. (2014). Effects of young maternal age and short interpregnancy interval on infant Page 3 HNPGP Knowledge Brief  mortality in South Asia. International journal of gynaecology and and finally (12) indicators of decision-making power for the obstetrics: the official organ of the International Federation of mother in the household. Gynaecology and Obstetrics, 124(1), 86. 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. Selected outputs under the study were gender; (3) whether the child had siblings born at the same time produced jointly with the International Center for Research on Women. (multiple birth); (4) the birth order of the child and the child’s birth 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; (11) whether the household practices polygyny; 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