BIRTH ORDER, STAGE OF INFANCY AND INFANT MORTALITY IN INDIA

Does a free maternity policy in Kenya work? Impact and cost-benefit consideration based on demographic health survey data

This paper evaluates the overall effect of the Kenyan free maternity policy (FMP) on the main outcomes (early neonatal and neonatal deaths) and intermediate outcomes (delivery through Caesarean Section (CS), skilled birth attendance (SBA), birth in a public hospital and low birth weight (LBW)) using the 2014 Demographic Health Survey. We applied the difference-in-difference (DID) approach to compare births (to the same mothers) happening before and after the start of the policy (June 2013) and a limited cost-benefit analysis (CBA) to assess the net social benefit of the FMP. The probabilities of birth resulting in early neonatal and neonatal mortality are significantly reduced by 17-21% and 19-20%, respectively, after the FMP introduction. The probability of birth happening through CS reduced by 1.7% after implementing the FMP, while that of LBW birth is increased by 3.7% though not statistically significant. SBA and birth in a public facility did not moderate the policy's effects on early neonatal mortality, neonatal mortality, and delivery through CS. They were not significant determinants of the policy effects on the outcomes. There is a significant causal impact of the FMP in reducing the probability of early neonatal and neonatal mortality, but not the delivery through CS. The FMP cost-to-benefit ratio was 21.22, and there were on average 4015 fewer neonatal deaths in 2013/2014 due to the FMP. The net benefits are higher than the costs; thus, there is a need to expand and sustainably fund the FMP to avert more neonatal deaths potentially.

How does a ban on sex-selective abortions affect child health?

Bans on sex-selective abortions are typically implemented to make sex ratios more equitable, but they may have adverse effects on surviving children. We examine the impacts of a ban on prenatal sex selection in India on postnatal health outcomes. We first show that the ban increased the share of female children born to mothers, especially among firstborn female families. Strikingly, we also find that the ban led to a worsening of mortality outcomes for both girls and boys in firstborn female families. In terms of mechanisms, we find that fertility increases in firstborn female families after the ban, pointing to the following channel: firstborn female families are disproportionately affected by the ban and are more likely to use the son-biased fertility stopping rule to achieve a desired number of sons. Children in firstborn female families likely face greater competition for parental resources, which may worsen their health.

Factors associated with infant mortality in Nigeria: A scoping review

BACKGROUND

Infant mortality persists as a global public health concern, particularly in lower-middle-income countries (LIMCs) such as Nigeria. The risk of an infant dying before one year of age is estimated to be six times higher in Africa than in Europe. Nigeria recorded an infant mortality rate of 72.2 deaths per 1,000 live births in 2020, in contrast to the global estimate of 27.4 per 1,000 live births. Several studies have been undertaken to determine the factors influencing infant mortality.

OBJECTIVE

This scoping review sought to identify and summarise the breadth of evidence available on factors associated with infant mortality in Nigeria.

METHODS

This review followed the five-stage principles of Arksey and O'Malley's framework. Four electronic databases were searched with no limit to publication date or study type: Ovid MEDLINE, PubMed, CINAHL Complete, and Web of Science. Selected studies were imported into Endnote software and then exported to Rayyan software where duplicates were removed. Included articles were thematically analysed and synthesised using the socioecological model.

RESULTS

A total of 8,139 references were compiled and screened. Forty-eight articles were included in the final review. At the individual level, maternal- and child-related factors were revealed to influence infant mortality; socioeconomic and sociocultural factors at the interpersonal level; provision and utilisation of health services, health workforce, hospital resources and access to health services at the organisational level; housing/neighbourhood and environmental factors at the community level; and lastly, governmental factors were found to affect infant mortality at the public policy level.

CONCLUSION

Factors related to the individual, interpersonal, organisational, community and public policy levels were associated with infant mortality in Nigeria.

Breastfeeding and female labor force participation: the probability of survival of children in Nepal under 3 years old

BACKGROUND

The number of breastfeeding mothers participating in a labor force to generate income has been increasing in Nepal. In this regard, the study aims to assess the survival of Under 3 children in Nepal from the mother based on their labor force participation and breastfeeding status.

METHODS

Data for the study were obtained from the Nepal Demographic and Health Survey 2016. The sample size of the study was 2,994 live births children, born in the last three years prior to the day of the interview. The robust hazard ratio and cox proportional hazard regression were conducted between dependent and independent variables with 95% confidence intervals (CIs) to conclude.

RESULTS

From a total of 2,994 live births, 85 children died within 36 months of birth. More than 80% of the non-working mothers were breastfeeding their children. The findings shows that the survival of children under-3 is positively associated with the interaction with the mother's work and breastfeeding status (Hazard Ratio 0.428, 95% CI 0.24, 0.75), family structure (Hazard Ratio 1.511; 95% CI 1.37, 1.655), relationship with the household head (Hazard Ratio 0.452; 95% CI 0.311, 0.65), wealth quintiles (Hazard Ratio 0.390; 95% CI 0.33, 0.46), caste (Hazard Ratio 0.652; 95% CI 0.60, 0.69), and religion (Hazard Ratio 2.015; 95% CI 1.09, 3.70) with model CI 95%, Log pseudo likelihood = -521.39236, prob. χ2 = 0.005 and time at risk = 52,748.

CONCLUSIONS

The highest rate of child survival was from the working mothers as well as continuing breastfeeding their children followed by mothers breastfeeding the child but not working, compared to mothers working but not breastfeeding the child, and mothers who were neither working nor breastfeeding their children respectively. This study provides clear evidence that breastfeeding is very important for the probability of survival of the child aged below 36 months and work of mother also have some positive impact on child survival. Employers should be encouraged to have a breastfeeding policy in the workplace through the establishment of a breastfeeding facility, and a flexible work schedule. At the same time government should also regulate the paid maternity leave and encourage societal support for the breastfeeding mothers.

Disease burden and attributable risk factors of neonatal disorders and their specific causes in China from 1990 to 2019 and its prediction to 2024

BACKGROUND

Neonatal health is a cornerstone for the healthy development of the next generation and a driving force for the progress of population and society in the future. Updated information on the burden of neonatal disorders (NDs) are of great importance for evidence-based health care planning in China, whereas such an estimate has been lacking at national level. This study aims to estimate the temporal trends and the attributable burdens of selected risk factors of NDs and their specific causes in China from 1990 to 2019, and to predict the possible trends between 2020 and 2024.

METHODS

Data was explored from the Global Burden of Disease study (GBD) 2019. Six measures were used: incidence, mortality, prevalence, disability-adjusted life years (DALYs), years lived with disability (YLDs), and years of life lost (YLLs). Absolute numbers and age-standardized rates (with 95% uncertainty intervals) were calculated. The specific causes of NDs mainly included neonatal preterm birth (NPB), neonatal encephalopathy due to birth asphyxia and trauma (NE), neonatal sepsis and other neonatal infections (NS), and hemolytic disease and other neonatal jaundice (HD). An autoregressive integrated moving average (ARIMA) model was used to forecast disease burden from 2020 to 2024.

RESULTS

There were notable decreasing trends in the number of deaths (84.3%), incidence (30.3%), DALYs (73.5%) and YLLs (84.3%), while increasing trends in the number of prevalence (102.3%) and YLDs (172.7%) from 1990 to 2019, respectively. The corresponding age-standardized rates changed by -74.9%, 0.1%, -65.8%, -74.9%, 86.8% and 155.1%, respectively. Four specific causes of NDs followed some similar and different patterns. The prediction results of the ARIMA model shown that all measures still maintained the original trends in the next five years. Low birth weight, short gestation, ambient particulate matter pollution and household air pollution from solid fuels were the four leading risk factors.

CONCLUSION

The health burden due to NDs is declining and is likely to continue to decline in the future in China. Delaying the increasing burden of disability may be the next target of concern. Targeted prevention and control strategies for specific causes of NDs are urgently needed to reduce the disease burden.

Women's education, contraception use, and high-risk fertility behavior: A cross-sectional analysis of the demographic and health survey in Ethiopia

Background

High-risk fertility behavior (HRFB) among women is the main factor in a wide range of detrimental effects on both the mother's and the child's health, which has an impact on both the mother's and the child's survival. Early childbearing is associated with a higher number of live births and may result in poorer maternal, baby, and child health outcomes. Infant and child mortality are also linked to short birth intervals and higher birth order. Thus, this study aims to examine the link between women's education, contraception use, and high-risk fertility behavior in Ethiopia.

Methods

Data was drawn from the 2019 Ethiopian Interim Demographic and Health Survey. The analysis covered a total of 5,846 women. The effect of predictor variables on HRFB was quantified using multivariable logistic regression analysis. At a 95% CI of the odds ratio excluding one, a significant association between the HRFB and predictor variables was observed.

Results

About 72.8% (95% CI 71.6%-73.9%) of women experience high-risk fertility behaviors. Of these, 32% experience single high-risk fertility behavior, and 40.8% experience multiple high-risk fertility behaviors. Of those who experience high-risk fertility behaviors, 58.7% have birth orders of more than three, 22.4% have short birth intervals (less than 24 months); 35.1% are old (over 34 years old); and 1.6% are young (less than 18 years old). Women with no education (AOR = 4.31; 95% CI: 2.09, 8.89) and primary education only (2.71; AOR = 2.71; 95% CI: 1.63, 4.50) are more likely to engage in high-risk fertility behaviors than women with a higher level of education. Every additional year of schooling reduces the odds of high-risk fertility behavior by 6% (AOR = 0.94; 95% CI: 0.89, 0.98). The use of modern contraception (AOR = 0.74; 95% CI: 0.622, 0.879) and knowledge of modern contraception methods (AOR = 0.80; 95% CI: 0.66, 0.96) reduce the risk of HRFB.

Conclusions

Primary education and a lack of education significantly raise the risk of HRFB. However, in Ethiopia, the risk of experiencing HRFB is reduced through modern contraceptive methods, awareness of modern contraceptive methods, and years of education. All initiatives to decrease maternal and newborn mortalities by reducing the risk of HRFB should educate women and encourage them to use modern contraception.

Prevalence and associated factors of neonatal mortality in Ethiopia

Neonatal mortality is the death of a live-born baby within the first 28 days of birth. For the selected households, neonatal mortality was collected from children aged 0–28 days and women aged 15–49. The neonatal period is a significant 4-week period in human life because it carries a greater mortality risk. To identify the determinant factors of neonatal mortality in Ethiopia based on EDHS 2016 data with the application of count regression models. In this study, all neonates in Ethiopia were born within the 5 years preceding EDHS 2016 of the source population in the selected EAs from September to December 2015. Count regression models were used to analyze the data. A total of 10,641 live-born neonates within the previous 5 years of EDHS 2016 had neonatal mortality of women aged 15–49, which was considered in the study to be 7193. The data were found to have excess zeros (96.6%), and the variance (0.052) was higher than its mean (0.04). The count regression model (ZINB) was best fitted to the data with maximum likelihood parameter estimation methods. The average neonatal mortality difference in multiple births was increased by IRR = 8.53 times compared with a single birth. The average number of neonatal deaths experienced during breastfeeding was lower (IRR = 0.38) than that experienced by mothers who did not experience breastfeeding their child. The average neonatal mortality difference in rural residences was increased by IRR = 3.99 times compared to urban mothers' residences. In this study, the prevalence of Neonatal mortality in Ethiopia was higher. For selected ZINB count regression models of explanatory variables, such as multiple birth types, having rural residence factors of neonatal mortality increased the risk of death. However, having early breastfeeding, a female household head, and antenatal visits (1–4) and (5–10) during pregnancy decrease the risk of neonatal death.

Examining infant and child death clustering among families in the cross-sectional and nationally representative Bangladesh Demographic and Health Survey 2017-2018

OBJECTIVES

We aim to examine the phenomenon of infant and child death clustering while considering the unobserved heterogeneity (frailty) at the family level.

DESIGN, SETTING, AND PARTICIPANTS

We analysed Bangladesh Demographic and Health Survey 2017-2018 data, including the birth history information for 47 828 children born to 18 134 women. We used Gompertz shared frailty model to control the correlation between event times at the mother level and capture the unobserved risks in infant and child deaths.

OUTCOME MEASURES

We estimated two sets of survival regression models where the failure event is the survival status of the index child during the infancy period, that is, from birth to 11 months, and childhood period, that is, between 12 and 59 months, respectively. All children who died during infancy and childhood were coded as 'yes'; otherwise, they were coded as 'no'.

RESULTS

About 2% of mothers experienced two or more infant deaths, and cumulatively these mothers account for 20% of all infant deaths in the sample. Children whose previous sibling was not alive at the time of their conception had 1.86 times (95% CI 1.59 to 2.17) more risk of dying as an infant. However, we did not find a statistically significant effect of death scarring on the risk of child mortality among siblings. Statistically significant frailty effect with a variance of 0.33 (95% CI CI 0.17 to 0.65) and 0.54 (95% CI 0.14 to 2.03)] in infancy and childhood, respectively, indicates the clustering of survival risks within families due to unobserved family-level characteristics shared by the siblings.

CONCLUSION

This study suggests that preceding birth interval, mother's age at first birth and mother's education are the most critical factors which can help in reducing scaring effect on infant mortality. Additionally, women from poor socioeconomic strata should be focused on as still an infant, and child mortality is concentrated among poor households.

Does higher early neonatal mortality in boys reverse over the neonatal period? A pooled analysis from three trials of Nepal

OBJECTIVES

Neonatal mortality is generally 20% higher in boys than girls due to biological phenomena. Only a few studies have examined more finely categorised age patterns of neonatal mortality by sex, especially in the first few days of life. The objective of this study is to examine sex differentials in neonatal mortality by detailed ages in a low-income setting.

DESIGN

This is a secondary observational analysis of data.

SETTING

Rural Sarlahi district, Nepal.

PARTICIPANTS

Neonates born between 1999 and 2017 in three randomised controlled trials.

OUTCOME MEASURES

We calculated study-specific and pooled mortality rates for boys and girls by ages (0-1, 1-3, 3-7, 7-14, 14-21 and 21-28 days) and estimated HR using Cox proportional hazards models for male versus female mortality for treatment and control groups together (n=59 729).

RESULTS

Neonatal mortality was higher in boys than girls in individual studies: 44.2 vs 39.7 in boys and girls in 1999-2000; 30.0 vs 29.6 in 2002-2006; 33.4 vs 29.4 in 2010-2017; and 33.0 vs 30.2 in the pooled data analysis. Pooled data found that early neonatal mortality (HR=1.17; 95% CI: 1.06 to 1.30) was significantly higher in boys than girls. All individual datasets showed a reversal in mortality by sex after the third week of life. In the fourth week, a reversal was observed, with mortality in girls 2.43 times higher than boys (HR=0.41; 95% CI: 0.31 to 0.79).

CONCLUSIONS

Boys had higher mortality in the first week followed by no sex difference in weeks 2 and 3 and a reversal in risk in week 4, with girls dying at more than twice the rate of boys. This may be a result of gender discrimination and social norms in this setting. Interventions to reduce gender discrimination at the household level may reduce female neonatal mortality.

TRIAL REGISTRATION NUMBER

NCT00115271, NCT00109616, NCT01177111.

Son preference and sex differentials in receipt of key dimensions of children's healthcare: Evidence from Pakistan

Almost all research on son preference and the consequent sex differentials in child health has focused on India. Pakistan-a country with the second strongest stated desire for sons, no evidence of sex-selective abortion, and relatively high fertility-offers a different context in which to understand unequal health outcomes for boys and girls. I use three rounds of the Pakistan Demographic and Health Survey to examine sex differentials in child healthcare receipt across different family contexts. I find evidence of generalized discrimination: all girls, regardless of sibling composition or birth order, are less likely to receive full immunization or medical treatment. I do not find evidence that girls with older sisters face greater discrimination than other girls. For boys, I find some evidence of selective preferential treatment: among larger families, first sons are more likely to receive healthcare than other sons or daughters.

Determinants associated with high-risk fertility behaviours among reproductive aged women in Bangladesh: a cross-sectional study

Background

We aimed to determine the factors that increase the risk of HRFB in Bangladeshi women of reproductive age 15–49 years.

Methods

The study utilised the latest Bangladesh Demographic and Health Survey (BDHS) 2017–18 dataset. The Pearson's chi-square test was performed to determine the relationships between the outcome and the independent variables, while multivariate logistic regression analysis was used to identify the potential determinants associated with HRFB.

Results

Overall 67.7% women had HRFB among them 45.6% were at single risk and 22.1% were at multiple high-risks. Women’s age (35–49 years: AOR = 6.42 95% CI 3.95–10.42), who were Muslims(AOR = 5.52, 95% CI 2.25–13.52), having normal childbirth (AOR = 1.47, 95% CI 1.22–1.69), having unwanted pregnancy (AOR = 10.79, 95% CI 5.67–18.64) and not using any contraceptive methods  (AOR = 1.37, 95% CI 1.24–1.81) were significantly associated with increasing risk of having HRFB. Alternatively, women and their partners’ higher education were associated with reducing HRFB.

Conclusion

A significant proportion of Bangladeshi women had high-risk fertility behaviour which is quite alarming. Therefore, the public health policy makers in Bangladesh should emphasis on this issue and design appropriate interventions to reduce the maternal HRFB.

High rates of maternal high-risk fertility behaviour (HRFB) have a variety of unfavourable repercussions for both the mother and the child. However, because there have been few studies on this topic to date, we set out to identify the determinants that enhance the risk of HRFB in Bangladeshi women between the ages of 15 and 49. Using latest demographic and health survey (BDHS) data we have found that 67.7% of women had HRFB, with 45.6% having a single high-risk factor and 22.1% having multiple high-risk factors. This high prevalence rate demonstrates that HRFB are all too common in Bangladesh, potentially endangering the health of the country's women. We found that women practicing Islam as core religion, age above 35 years, having normal childbirth, having above 3 children, having unwanted pregnancies and not using birth control methods were at increased risk of having HRFB. As a result of the study's findings, interventions are urgently needed to prevent high-risk fertility behaviour among Bangladeshi women aged 15 to 49 years.

Exploring the effects of birth order on human lifespan in Polish historical populations, 1738–1968

While the relationships between birth order and later outcomes in life, including health and wealth, have been the subject of investigation for several decades, little or no data exist regarding the relationship between birth order and life expectancy in the Polish population. The aim of this study was to explore the link between birth order and lifespan in Polish historical populations. We obtained 8523 records from a historical dataset that was established for parishioners from the borough of Bejsce, including 4463 males and 4060 females. These data pertain to the populations that lived over a long period in a group of localities for which parish registers were well preserved. The Mann-Whitney U test, the Kruskal-Wallis ANOVA and ANCOVA were run. The results strongly suggest that birth order affects male longevity. However, no such association was found for females. On balance, the hypothesis that first-born boys live longer because they are born to relatively younger parents has received some empirical support and deserves further study. We hypothesise that the effects of birth order on human health and lifespan might be overshadowed by other factors, including educational attainment, socioeconomic status and lifestyle.

Preceding child survival status and its effect on infant and child mortality in India: An evidence from National Family Health Survey 2015-16

Background

India has achieved impressive gains in child survival over the last two decades; however, it was not successful in attaining MDG 2015 goals. The study’s objective is to inquire how the survival status of the preceding child affects the survival of the next born child.

Methods

This is a retrospective analysis of data from the National Family Health Survey, 2015–16. Analysis was restricted to women with second or higher-order births because women with first-order births do not have a preceding child. Proportional hazards regression, also called the Cox regression model, has been used to carry out the analysis. Kaplan–Meier (K–M) survival curves were also generated, with a focus on preceding birth intervals.

Results

Results found that female children were more likely to experience infant mortality than their male counterparts. Children born after birth intervals of 36+ months were least likely to experience infant mortality. Mother’s education and household wealth are two strong predictors of child survival, while the place of residence and caste did not show any effect in the Cox proportional model. Infant and child deaths are highly clustered among those mothers whose earlier child is dead.

Conclusion

Maternal childbearing age is still low in India, and it poses a high risk of infant and child death. Education is a way out, and there is a need to focus on girl’s education. The government shall also focus on raising awareness of the importance of spacing between two successive births. There is also a need to create a better health infrastructure catering to the needs of rich and poor people alike.

Birth order, stimulating environment, and maternal factors in developmental outcomes: A longitudinal Mexican study

This study longitudinally examined the interplay between birth-order and well-known risk factors in impoverished environments such as inadequate environmental stimulation, low maternal education, and young maternal age in children from birth to 36 months. In the developmental motor domain, the effect of the stimulating environment over time, favored first-borns. In the adaptive domain, maternal education privileged first-born boys. In language development, first-borns reached higher scores over time than laterborn identifying a positive impact of stimulation. In the personal-social domain, firstborns obtained higher averages overall, but stratified models revealed that later-borns reached the first-borns scores as maternal age increased.

Differential in infant, childhood and under-five death clustering among the empowered and non-empowered action group regions in India

Background

With 8,82,000 deaths in the under-five period, India observed varied intra-state and inter-regional differences across infant and child mortality in 2018. However, scarce literature is present to capture this unusual concentration of mortality in certain families by examining the association of the mortality risks among the siblings of those families along with various unobserved characteristics of the mother. Looking towards the regional and age differential in mortality, this paper attempts to provide evidence for the differential in mortality clustering among infants (aged 0–11 months), children (12–59 months) and under-five (0–59 months) period among mothers from the Empowered Action Group (EAG) and non-EAG regions of India.

Methods

The study used data from the National Family Health Survey (2015–16) which includes all the birth histories of 475,457 women aged 15–49 years. Bivariate and multivariate analyses were used to fulfil the objectives of the study. A two-level random intercept Weibull regression model was used to account for the unexplained mother (family) level heterogeneity.

Results

About 3.3% and 5.9% of infant deaths and 0.8% and 1.6% of childhood deaths were observed in non-EAG and EAG regions respectively. Among them, a higher percentage of infant and child death was observed due to the death of a previous sibling. There were 1.67 times [95% CI: 1.55–1.80] and 1.46 times [CI: 1.37–1.56] higher odds of infant and under-five mortality of index child respectively when the previous sibling at the time of conception of the index child was dead in the non-EAG regions. In contrast, the odds of death scarring (death of previous sibling scars the survival of index child) were 1.38 times [CI: 1.32–1.44] and 1.24 times [CI: 1.20–1.29] higher for infant and under-five mortality respectively in the EAG regions.

Conclusion

The extent of infant and child mortality clustering and unobserved heterogeneity was higher among mothers in the non-EAG regions in comparison to their EAG region counterparts. With the growing situation of under-five mortality clustering in non-EAG states, region-wise interventions are recommended. Additionally, proper care is needed to ameliorate the inter-family variation in mortality risk among the children of both EAG and non-EAG regions throughout their childhood.

Under-5 mortality and morbidity outcomes of fertility postponement in Turkey: explanations by observed and unobserved characteristics

This paper investigates the association between advanced maternal age and under-5 mortality and morbidity in Turkey, and is the first such study in the country to use a sibling comparison model to analyze this phenomenon. The study is based on data obtained from the 2013 Turkey Demographic and Health Survey, and analyzes the association of advanced maternal age with: (1) under-five mortality, using Cox proportional hazard models and their stratified versions to compare sibling groups born to the same mother in the 1978-2013 period, and (2) under-five morbidity; specifically, being born with low birth weight, stunting, underweight, and wasting based on between- and within-sibling groups models for the 2008-2013 period. Overall, our findings suggest that the hazard of under-5 mortality increases as maternal age increases. We conclude that period effects have failed to reverse the impeding effects of advanced maternal age on child mortality. Between-sibling group models indicate a positive but close to null association between advanced maternal age and child morbidity in general, although these positive associations vanish once we apply within-sibling group models. This result can be partially attributed to our controlling for unobserved characteristics specific to sibling groups, in addition to other methodological differences.

Gender variations in neonatal and early infant mortality in India and Pakistan: a secondary analysis from the Global Network Maternal Newborn Health Registry

Background

To determine the gender differences in neonatal mortality, stillbirths, and perinatal mortality in south Asia using the Global Network data from the Maternal Newborn Health Registry.

Methods

This study is a secondary analysis of prospectively collected data from the three south Asian sites of the Global Network. The maternal and neonatal demographic, clinical characteristics, rates of stillbirths, early neonatal mortality (1–7 days), late neonatal mortality (8–28 days), mortality between 29–42 days and the number of infants hospitalized after birth were compared between the male and female infants.

Results

Between 2010 and 2018, 297,509 births [154,790 males (52.03%) and 142,719 females (47.97%)] from two Indian sites and one Pakistani site were included in the analysis [288,859 live births (97.1%) and 8,648 stillbirths (2.9%)]. The neonatal mortality rate was significantly higher in male infants (33.2/1,000 live births) compared to their female counterparts (27.4/1,000, p < 0.001). The rates of stillbirths (31.0 vs. 26.9/1000 births) and early neonatal mortality (27.1 vs 21.6/1000 live births) were also higher in males. However, there were no significant differences in late neonatal mortality (6.3 vs. 5.9/1000 live births) and mortality between 29–42 days (2.1 vs. 1.9/1000 live births) between the two groups. More male infants were hospitalized within 42 days after birth (1.8/1000 vs. 1.3/1000 live births, p < 0.001) than females.

Conclusion

The risks of stillbirths, and early neonatal mortality were higher among male infants than their female counterparts. However, there was no gender difference in mortality after 7 days of age. Our results highlight the importance of stratifying neonatal mortality into early and late neonatal period to better understand the impact of gender on neonatal mortality. The information from this study will help in developing strategies and identifying measures that can reduce differences in sex-specific mortality.

Gender Discrimination and Excess Female Under-5 Mortality in India: A New Perspective Using Mixed-Sex Twins

Son preference has been linked to excess female under-5 mortality in India, and considerable literature has explored whether parents invest more resources in sons relative to daughters—which we refer to as explicit discrimination—leading to girls’ poorer health status and, consequently, higher mortality. However, this literature has not adequately controlled for the implicit discrimination processes that sort girls into different types of families (e.g., larger) and at earlier parities. To better address the endogeneity associated with implicit discrimination processes, we explore the association between child sex and postneonatal under-5 mortality using a sample of mixed-sex twins from four waves of the Indian National Family Health Survey. Mixed-sex twins provide a natural experiment that exogenously assigns a boy and a girl to families at the same time, thus controlling for selectivity into having an unwanted female child. We document a sizable impact of explicit discrimination on girls’ excess mortality in India, particularly compared with a placebo analysis in sub-Saharan Africa, where girls have a survival advantage. We also show that explicit discrimination weakened for birth cohorts after the mid-1990s, especially in northern India, but further weakening has stalled since the mid-2000s, thus contributing to understandings of how the micro-processes underlying the female mortality disadvantage have changed over time.

Association between Maternal High-Risk Fertility Behavior and Childhood Morbidity in Bangladesh: A Nationally Representative Cross-Sectional Survey

In this cross-sectional study, we evaluated data from the 2014 Bangladesh Demographic and Health Survey (BDHS), which consisted of 7,707 married women aged 15-49 years who lived with at least one child younger than 5 years. This study's primary aim was to examine the relationship between maternal high-risk fertility behavior and child morbidity. To define high-risk fertility behaviors, we considered three variables: maternal age at the time of delivery, birth order, and birth interval. The main outcome measures were mortality-related disease in the past 2 weeks (acute respiratory infection [ARI], diarrhea, and fever) and low birth weight (LBW). We used modified Poisson regression with generalized estimating equations to assess the relationships between the variables of interest. Results indicate that a substantial portion of women (34%) exhibited high-risk fertility patterns; 28.7% engaged in a single high-risk behavior and 5.4% engaged in multiple high-risk behaviors. After adjusting for relevant covariates, high-risk fertility behaviors were significantly associated with an increased likelihood of ARI (adjusted relative risk [ARR]: 1.22, 95% CI: 1.05-1.50), diarrhea (ARR: 1.18, 95% CI: 1.03-1.35), fever (ARR: 1.29, 95% CI: 1.11-1.58), and LBW (ARR: 1.27, 95% CI: 1.10-1.52). In addition, engaging in multiple high-risk fertility behaviors appeared to have far-reaching consequences on the outcomes measured. Maternal high-risk fertility behaviors are important predictors of morbidity in children younger than 5 years. Preventing high-risk fertility behavior may reduce childhood morbidity and mortality in Bangladesh.

Associations Between Sex Composition of Older Siblings and Infant Mortality in India from 1992 to 2016

BACKGROUND

This study examines associations between sex composition of older siblings and infant mortality by sex, to guide efforts to address excess female infant mortality in India.

METHODS

We conducted a retrospective cross-sectional study of infant mortality in India using four waves of data from the nationally-representative National Family Health Survey, collected between 1992 and 2016 (unweighted N = 338,504 for children aged 1-5). We used sex-stratified multivariable logistic regression models to assess the associations between sex composition of older siblings and risk of infant mortality.

FINDINGS

Male infants with two living older sisters and no living older brothers had lower odds of infant mortality relative to those with one living older brother (e.g., 2015-16 AOR 0.62, 95% CI 0.50-0.76); this effect was significant for boys across all waves of data but was not seen for girls in any wave. Exploratory models focused on third order births found that boys were less likely than girls to die in infancy if born subsequent to two older sisters (2015-16 AOR 0.48, 95% CI 0.31-0.74); analysis of crude prevalence data indicated that this converts into a 64% greater risk for infant mortality for girls relative to boys in this third-order group.

INTERPRETATION

Higher birth order males with older sisters have greater protection against infant mortality, a finding that has persisted for over 25 years. To address ongoing gender inequities in infant survival in India, greater focus is needed to support higher birth order girls and social norm movements against son preference.