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V-
Center for Population and Family Health
School of Public Health
Faculty of Medicine
Columbia University, New York
he Center gratefully acknowledges the
upport of the United States Agency for
iternational Development (Cooperative
agreement DPE-3030-00-4049-00) that
lade possible the preparation, publication,
nd distribution of this report.
11 it ii 1it1
Birth Spacing
and
Child Survival
Deborah Maine, M.P.H.
Regina McNamara, Dr.P.H.
Hl
CH - | q q
COMMUNITY HEALTH C’LL
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47/1. (First Floor; St. fc»rks rm j
Banqalore - 560 001.
Copyright ©1985 by the Center for Population and Family
Health, Columbia University. All text and charts in this
publication may be reproduced without permission, as
long as the material is distributed free of charge and credit
is given to the authors and publisher.
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Contents
How to Use this Chartbook
Introduction
Chapter 1: Risks and Benefits
Chapter 2: Program Implications
Chapter 3: Questions and Answers
References
Acknowledgments and Credits
2
How to Use this
Chartbook
This chartbook is designed to be
used in a variety of ways:
As a briefing booklet. If you
only have a little time but want to
know the most important facts
about birth spacing and child
survival, read the large print in
Chapter 1 and the bold print in
Chapter 2.
As an information booklet.
If you want more detail, read the
other sections as well.
As a guide to further
study. If you would like to learn
more or explore a particular
issue, look up the relevant
references from the numbers
given in the text.
If you have trouble getting
the documents you want, the
Center’s library can help you
obtain them. Address requests
for assistance to the Library,
Center for Population and
Family Health, Columbia
University, 60 Haven Avenue,
NewYork, N.Y. 10032 USA.
3
Introduction
A child’s chances of dying can be increased by
many factors, including malnutrition, infectious
illnesses, and lack of health care. In the long
run, if death rates among children in developing
countries are to be substantially reduced, we
must work to correct all these conditions, along
with the poverty that usually underlies them.
But what can we do to prevent deaths now?
One promising way is to encourage parents to
space the births of their children. The
importance of birth spacing and its potential for
improving child survival are the subjects of this
chartbook.
The book is divided into three chapters.
Chapter 1 presents data on the high risk of
childhood death that is linked to short birth
intervals, and on the improvement in child
survival that good spacing promises.
Chapter 2 discusses some of the implications
of these data for health programs.
Chapter 3 addresses questions people often
ask about birth spacing, including, “Who has
short birth intervals?” and “Why are short birth
intervals dangerous to children’s health?”
Chapter 1
Risks and Benefits
Chart 1
Percent of children who will die in the
first 5 years of life
Region
Africa
Every day, 40,000 children less
than 5 years old die, most of
them in developing countries.1
Among children born this
year, about 1 in 5 Africans, 1 in
6 Asians*, and 1 in 10 Latin
Americans will not live to see
their fifth birthday.2 By
comparison, fewer than 1 of
every 50 children born in Europe
or North America will die before
they are 5 years old.
‘Not including the People’s Republic of China.
Source: Derived from ref. 2.
Latin America
Asia*
Europe
North America
Three aspects of childbearing influence child
survival: birth spacing, maternal age, and birth
order.3-5 Of these, birth spacing is the most
powerful factor. Until recently, however, we had
relatively little information on birth spacing, and
most of the information we did have was from
industrialized countries.3-6
In the last few years, this situation has
changed as a result of the World Fertility
Survey (WFS). This is a series of surveys
conducted in dozens of developing countries
during 1972-1982. In these surveys, women
aged 15 through 49 were asked, among other
things, about the number, timing, and survival
of their children.
Thanks to the WFS, we now have a wealth of
information on birth spacing and child survival
from Third World countries. Furthermore,
because the surveys were conducted and
analyzed in a standardized manner, the
findings from various countries can be
compared. The data presented in this report
are drawn almost entirely from the WFS—
either from the country reports, or from special
analyses of the data.
6
The length of time between two
births in a family (the “birth
interval”) greatly influences
child survival. When two
children in a family have a short
birth interval between them,
both have a much greater
chance of dying than do children
with a longer interval between
them.
Birth intervals less than
2 years long are too short-the
shorter, the more hazardous.
Birth intervals of 3 or more years
usually carry the least risk.
Charts 2,3, and 4 show
death rates among children with
short birth intervals compared to
death rates among children with
longer birth intervals.
Child Born
at the Start
of the Interval
Child Born
at the End
of the Interval
As children grow older, they become stronger
and better able to resist and recover from
illnesses. As a result, most deaths among
young people take place before age 5, and
most of these deaths occur in the first year of
life (infancy). The increase in deaths
associated with short-interval births is also
usually greatest during the first year. The
combination of these effects results in
extremely high rates of infant death among
children born at the end of a short interval.
Sometimes the interval between births is
short because the younger child was born a
month or two early. Such babies are quite likely
to die soon after birth, especially in developing
countries. However, taking premature births
into account reduces the effect of short-interval
births only slightly.7-8
Data on deaths in infancy are shown for
24 countries (Chart 2), while data on deaths at
1-4 years of age are available for 20 countries
(Charts 3 and 4).
In this book, the effect of birth spacing on
children born at the start of a short interval is
discussed only in terms of deaths at 1-4 years
of age. One of the reasons for this is that, in
most cases, the older child of the pair of
siblings is already 9 months old (i.e., most of
the way through infancy) when the next child is
born. Nevertheless, a short birth interval
probably harms the older child of the pair even
before the younger is born: the mother may
wean the older child too early because she is
pregnant again.
8
The clanger to child survival
posed by short birth intervals is
greatest in the first year of life
(infancy). In developing
countries, children who are born
at the end of a birth interval of
less than 2 years are, on
average, twice as likely to die in
infancy as are children born
after a long interval.*
Chart 2 shows infant death
rates among children born less
than 2 years after their next
older brother or sister, and death
rates among infants born after a
longer birth interval. In every
country for which we have these
data, children born at the end of
a short interval have
substantially higher death rates
than do other children.9
Chart 2
Death rates among infants born at the
end of a short or a long birth interval!
■ Long Interval
□ Short Interval
Region/Country
Africa
Ghana
Kenya
Lesotho
9
Senegal
Sudan
Latin
America
Colombia
Costa Rica
Ecuador
Haiti
Jamaica
Mexico
Panama
Peru
Asia
Bangladesh
Indonesia
Jordan
Korea
Malaysia
Nepal
Pakistan
Philippines
Sri Lanka
‘Averages are medians unless otherwise specified.
Syria
■j’These are deaths in the first year of life per 1,000 live
births. A short interval is less than 2 years; a long interval
is 2-6 years.
Thailand
Source: Derived from ref. 9, T.7.
Death Rate
As everyone knows, poor children are more
likely to die than are children of wealthy
families. So, it is important to take into account
the effects of poverty when studying the
influence of birth spacing on child survival. In
many developing countries, cash income is not
a good way to measure a family’s wealth. For
example, farmers often trade their produce for
goods and services, without any money
changing hands. Researchers have found that
the education of the mother is a useful indicator
of standard of living in developing countries.
Furthermore, mother’s education is closely
related to child survival, even more so than
father’s education or occupation.10
In Charts 2,3, and 4, only the children of
uneducated women are included. Excluding
the children of educated women does not
distort the findings because uneducated
women far outnumber educated women in
most developing countries, and because WFS
researchers found that there is little interaction
between education and the size of the increase
in death rates associated with short-interval
births.9 Of course, overall mortality rates are
much higher among the children of uneducated
women.
10
Although the increased risk of
death linked to short birth
intervals weakens as children
grow older, it lasts until they are
at least 5 years old. On average,
children born either at the start
or at the end of a short interval
are 50% more likely to die at
ages 1-4 than are other
children.9
Chart 3 shows the effect of
birth spacing on the survival of
the child born at the start of the
birth interval. Death rates at
1-4 years of age among
children born at the start of a
short interval are compared to
those among children born at
the start of a longer interval. In
19 of the 20 countries for which
we have data, short birth
intervals pose a substantial risk
to the health of young children.
Chart 3
Death rates at 1-4 years of age among
children born at the start of a short or
a long birth interval*
Long Interval
Short Interval
11
‘These are deaths per 1,000 children aged 1-4, per year.
For children under 2 years of age, a short interval is less
than 18 months. For children aged 2-4, a short interval is
less than 30 months. Long intervals are those with no
births in those time periods.
Source: Derived from ref. 9, T. 8.
225
250
There is no obvious reason why birth spacing
has a large effect in some countries and a
relatively small one in others. The size of the
effect does not vary systematically with
geographic region, level of infant mortality, nor
proportion of births that have short intervals.
Furthermore, the ranking of individual
countries varies greatly. For example, in
Lesotho, there is a large difference in death
rates between short-interval and long-interval
children in Chart 3, but not in Chart 4.
Among children aged 1-4, the data from
Senegal do not show the usual birth spacing
effect. We don’t know why this is so. If one were
to accept the data shown in Charts 3 and 4, this
would mean that in Senegal short birth
intervals improve child health! This is not
believable, because information from dozens
of other countries shows the opposite.
Furthermore, the WFS results from Nigeria
(which have not yet been fully analyzed, and so
are not included in the charts) also show a
substantial excess in deaths among infants
and toddlers born at the end of short birth
intervals.11 There are, however, several other
studies in Africa that have not found an
increased risk of childhood deaths among
short-interval births.12-15 Whether these odd
findings are explained by methodological
problems in the studies or reflect real
differences remains to be seen.
12
Chart 4 shows the effect of birth
spacing on the survival of the
child born at the end of the birth
interval. Deaths at 1-4 years of
age among children born at the
end of a short interval are
compared to those among
children born after a longer
interval. Again, the data for all
but one of the countries show
that short birth intervals
seriously endanger the health of
young children.
Charts 3 and 4 show the
increased risk of death among
children born either at the start
or at the end of a short birth
interval. Children who are
unfortunate enough to 1*$ born
at both the start and the end of
short birth intervals have, on
average, twice the risk of death
in early childhood as children in
families with well-spaced
births.9
‘These are deaths per 1,000 children aged 1-4, per year.
A short interval is less than 2 years; a long interval
is 2-6 years.
Source: Derived from ref. 9, T. 8.
Chart 4
Death rates at 1-4 years of age among
While there is no clear pattern in the increase of
childhood death rates associated with short
intervals, there is an obvious pattern in the
frequency of short intervals. As Table 1 shows,
3 of the 4 countries in which less than 20% of
births follow short intervals are in Sub-Saharan
Africa. Five of the 7 countries in which at least
40% of births follow short intervals are in Latin
America.
Table 1
Percent of all children boni at the end o
an interval of less than 241nonths
Region/Count ry
Africa
Cameroon
Ghana
Kenya
Sudan
Lesotho
Senegal
14
Latin
America
Ecuador
Haiti
Peru
Costa Rica
Colombia
Jamaica
Mexico
Panama
Asia
Korea
Nepal
Indonesia
Bangladesh
Malaysia
Jordan
Pakistan
Sri Lanka
Philippines
Syria
35-39
40 +
Thailand
16-19
Percent
Source: Derived from refs. 9, T. 2, and 16.
20-24
25-29
30-34
Unfortunately, short-interval
births are quite common. The
proportion of all children born at
the end of an interval less than
2 years long ranges from only
16% in Lesotho and Korea to
more than 45% in Jordan,
Colombia, and Costa Rica. (See
Chart 5.) In these 25 countries,
on average, 1 child in 3 is born at
the end of a short interval. Even
in countries where short-interval
births are least common (e.g.,
Lesotho), at least 1 child in 6 is
born with this handicap.
Chart 5
Percent of all children born at the end
of a short birth interval*
Region/Country
Africa
Cameroon
Ghana
Kenya
Lesotho
Senegal
Sudan
Latin
America
Colombia
Costa Rica
Ecuador
Haiti
Jamaica
Mexico
Panama
Peru
Asia
Bangladesh
Indonesia
Jordan
Korea
Malaysia
Nepal
Pakistan
Philippines
Sri Lanka
Syria
*A short interval is less than 2 years.
Source: Derived from refs. 9, T. 2, and 16.
Thailand
Because we have data on both the effects of
birth spacing and how common short intervals
are, we can estimate how much difference in
child survival it would make if all births were
well-spaced. Other researchers have used
other methods to make this kind of estimate,
with somewhat different results.17
Methodology for Estimating Infant
Deaths Averted
1. For each country, we determined the
proportion of all births that followed short
intervals (less than 24 months).9’7-2-16
2. We determined the infant mortality rates
among infants born after short and long
intervals.18119
Example: Kenya
Pn = 0.65
/n =68
Ps = 0.35
/s =117
lo = 0.65(68) + 0.35(117) = 85.15
Deaths averted =----------------- = 20%
85
16
3. Then we calculated the percent of deaths
attributable to short birth intervals, using the
following formula:20
/p-/n
Io
Where:
/o
= Pnl„ + PSlS
= infant mortality rate in the
population, excluding first births
and the few births after intervals of
more than 6 years.
/n
= infant mortality rate after long
intervals (24-47 months)
/s
= infant mortality rate after short
intervals (<24 months)
Pn = proportion of births at long intervals
Ps = proportion of births at short intervals
We have seen that short birth
intervals are associated with
high rates of childhood death,
and that short birth intervals are
common. What would happen if
all couples waited at least
2 years before having their next
child?
Chart 6 shows the estimated
reduction in infant deaths if all
children were born after an
interval of at least 2 years. The
reduction in infant deaths would
range from 5% in Senegal to
40% in Jordan. On average,
about 1 out of 5 infant deaths
would be averted through good
birth spacing.
Chart 6
Estimated reduction in infant deaths
if all children were born at the end of
birth intervals at least 2 years long*
Region/Country
Africa
Cameroon
Ghana
Kenya
17
Lesotho
Senegal
Sudan
Latin
America
Colombia
Costa Rica
Ecuador
Haiti
Jamaica
Mexico
Panama
Peru
Asia
Bangladesh
Indonesia
Jordan
Korea
Malaysia
Nepal
Pakistan
Philippines
Sri Lanka
Syria
Thailand
‘These are deaths in the first year of life per 1,000 live births.
45
Percent
50
00
Chapter 2
Program Implications
Chapter 1 has shown that
improving birth spacing could
prevent the deaths of many
children in developing countries.
Is this a realistic goal? In this
chapter several factors are
discussed that make birth
spacing a feasible and
important component of child
survival programs.
In most societies, birth
spacing is not a new idea.
Science often confirms what
people have learned through
experience. This is clearly the
case with birth spacing.
In a World Health Organi
zation study more than 42,000
women were interviewed in
Latin America, North Africa, and
Asia.2122 More than 9 out of
every 10 women said that short
birth intervals harm child health.
In many societies in
Sub-Saharan Africa there are
long-standing traditions of
spacing births for health
reasons.23 For example,
Nigerian and Togolese women
say that a birth interval of more
than 2 years is healthiest.24 In
Zimbabwe it is said that children
born too close together “burn”
each other.25
There are many ways to space
births-some traditional,
some modern.
People have been spacing births
for thousands of years using
such methods as withdrawal,
abstinence, and prolonged
breastfeeding. So, while it is best
to make a range of effective
methods of contraception easily
accessible to all people, couples
should be encouraged to use
whatever means they can to
postpone their next pregnancy
for a few years.
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21
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COMMUNITY HZV.T4C~LL
47/1. (First Hoor, St. Marks Road,
Bangalore - 560 001.
Birth spacing is a step toward
child survival that couples
can take on their own.
Parents everywhere want their
children to live and develop well,
but in poor countries there is
often little that they can do to
make this wish come true. Good
spacing of births is an action that
couples can take on their ownwhether they are rich or poor,
whether they live in a city or in a
village-to improve the health of
their children. Parents and
policymakers need to
understand this important fact.
22
Birth spacing complements
other child survival activities.
Programs to encourage birth
spacing can work together with
other child survival activities,
such as programs of immuniz
ation or of oral rehydration for
diarrheal diseases. When
health workers are talking to
mothers about the health
benefits of immunization, oral
rehydration, and breastfeeding,
they can easily discuss the
benefits of good birth spacing.
Family planning services
can be supplied in a variety
of programs.
A number of international
agreements state that all people
have a right to decide on the
number and timing of their
children.26 Unfortunately,
millions of people live in rural
areas or crowded slums where it
is difficult or impossible to obtain
family planning advice and
supplies. In these areas, there
are also usually shortages of
resources and personnel.
Forthese reasons it is
extremely fortunate that there
are a number of contraceptive
methods that can be dispensed
safely by nonmedical
personnel.27-30 In many
countries, condoms, foaming
tablets, and oral contraceptives
are sold in pharmacies or
dispensed by village volunteers
who have received some
training.
Chapter 3
Qoesfo©ns and
Answers
This chapter addresses some of
the questions that may come to
mind, such as: “What groups of
people are most likely to have
short interval births?” or “Are
some kinds of children more
affected than others by short
birth intervals?”
The answers to these
questions are based on in-depth
analyses of World Fertility
Survey data from Cameroon,
Ghana, Indonesia, Kenya, and
Mexico.7’16 These analyses
were carried out at Columbia
University’s Center for
Population and Family Health.
Question:
How short a birth interval is too
short?
Chart 7
Infant death rates among children born
at the end of birth intervals of less
than 2 years, of 2 years, and of 3 years*
Cameroon
Answer:
Less than 2 years is definitely
too short. Furthermore, a child’s
chances of surviving are better
with a 3-year interval than with a
2-year interval.
26
Ghana
Kenya
Interval in Years
Deaths per 1,000
Indonesia
Interval in Years
‘Probability of death during the first year of life per
1,000 live births. Interval categories are <24, 24-35,
and 36-47 months.
Question:
Are younger women more likely
than older women to have
closely-spaced births?
Chart 8
Percent of children born at the end of
birth intervals less than 2 years long,
by mothers’ age
Cameroon
Mothers’ Age
Answer:
Yes. Women less than 20 years
old have the highest proportion
of short-interval births of any
age group, ranging from 39% in
Ghana to 69% in Mexico.
Kenya
Mothers' Age
Percent
Indonesia
Mothers’ Age
Question:
Are uneducated women more
likely than educated women to
have closely-spaced births?
Answer:
Apparently not. In the WFS as
a whole, there was no clear
association between short birth
intervals and education.31
In the 5 countries for which
we have in-depth data, women
with 4 or more years of
schooling often have somewhat
higher proportions of short
interval births than do less
educated women. This may be
due to the fact that, in some
developing countries,
breastfeeding has declined
among educated women.32
Many of these women are
not yet using modern
contraceptives to space their
pregnancies.
*Not available
Chart 9
Percent of children born at the end of
birth intervals less than 2 years long,
by mothers’ education
Indonesia
Years of Schooling
Percent
Question:
Are rural women more likely
than urban women to have
closely-spaced births?
Answer:
No. City women in 4 of these 5
countries had somewhat higher
proportions of short-interval
births than did women living in
the countryside.This finding may
be due, at least in part, to
declines in breastfeeding and
postpartum sexual abstinence
among urban women.
Chart 10
Percent of children born at the end of
birth intervals less than 2 years long,
by area of residence
Cameroon
Mexico
29
Ghana
Indonesia
Kenya
Question:
Does having a short birth
interval pose more danger to
some children than to others?
For example, are short birth
intervals more dangerous for the
children of uneducated than of
educated mothers?
Answer:
Perhaps. In Chart 11, the
difference in death rates
associated with short birth
intervals is somewhat greater
among children of uneducated
women than among children of
educated women. However,
in the WFS as a whole, no
significant relationship between
the mother’s education and the
effect of birth spacing was
found.9
The important point is that
short birth intervals are a
serious threat to the health of all
children.
*A short interval is less than 2 years; a long interval is
greater than 2 years.
Chart 11
Infant deaths among children born at the
end of a short or a long birth interval,*
by mothers’ education
Cameroon
Long Interval
□ Short Interval
Mexico
Years of Schooling
30
180
Ghana
Kenya
Years of Schooling
180
Indonesia
Years of Schooling
Question:
Are short birth intervals more
dangerous for rural than for
urban children?
Answer:
In some countries, apparently
so. It appears that living in a city,
especially a large one, can
offset some of the danger
associated with short birth
intervals, at least in 4 of these
5 countries. This effect may be
due to better access to medical
care in urban centers. But even
in large cities, short birth
intervals substantially increase
children’s chances of dying.
Chart 12
Infant deaths among children born at the
end of a short or a long birth interval,*
by area of residence
LJ Long Interval
Cameroon
Mexico
Ghana
Kenya
Indonesia
*A short interval is less than 2 years; a long interval is
greater than 2 years.
0 Short Interval
Question:
Do factors such as education
and rural residence, rather than
birth spacing itself, account for
the apparent effect of birth
spacing on childhood death
rates?
Answer:
No. First, although the risk of
death associated with short
intervals varies somewhat, it is
not much reduced when these
other factors are taken into
account.
Second, the effect of birth
interval on child survival during
the first 2 years of life is often
stronger than that of other
factors, including maternal
education.9’16
Question:
For many years, studies have
shown that infants born to very
young and very old mothers,
and to women who already have
3 or more children, are more
likely to die than are other
infants. Does the effect of birth
interval remain when these
factors are taken into account?
Answer:
Yes. In fact, we now know that
birth interval usually has a more
powerful effect on child survival
than do these other factors.
When birth interval is included in
the analysis, the effects of
maternal age and birth order are
often greatly reduced, and
sometimes even disappear.15
The previous charts have shown
that:
1. Short-interval births are
common among all groups of
people, regardless of residence,
education, and maternal age.
2. In all groups, short birth
intervals are linked to lower
rates of child survival.
3. The effect of birth interval
is not the result of such other
factors as maternal age, birth
order, and maternal education.
But why are short birth
intervals a hazard to child
survival? Unfortunately, we do
not know the answer to this
question. Furthermore,
exploring the WFS data has not
provided strong clues. In fact,
analysis of these data has
weakened some of the most
commonly cited explanations.
32
Question:
One theory about birth spacing
is that closely-spaced children
compete for food and the
attention of their parents. Is this
competition a major cause of the
birth spacing effect on
child survival?
Answer:
No. Competition within the
family cannot explain much of
the effect of birth spacing. For
example, the high risk of death
for children with a short interval
between them does not change
even if one of the children dies.
The surviving child will still have
a high risk of death for several
more years.33-35 If competition
were a major reason for the
effect of birth spacing, the risk of
death would decrease after the
death of the other sibling.
Question:
Could it be that short birth
intervals are not a cause of child
death but just a characteristic of
families at high risk for other
reasons?
Answer:
This does not seem to be the
case. First of all, previous charts
have demonstrated that short
intervals pose a danger to
children in families with the
advantages of education and
urban residence, as well as to
children in disadvantaged
families. Secondly, one sign of a
“high-risk” family is the death of
a child. But the effect of birth
spacing is not much stronger in
these families than in families
where earlier children have not
died.7’8’15’16
Question:
If a woman has several births in
a short span of time, this must
be a great strain on her strength.
Could it be that this strain, called
“maternal depletion,” explains a
large part of the birth spacing
effect?
Answer:
No. While depletion of the
mother’s resources might
explain some of the effect of
birth spacing on the survival of
newborns, it seems less likely to
explain deaths among older
children.
33
co
Conclusion:
There is no easy way to explain.
away the powerful and
persistent relationship between
birth spacing and child survival.
Perhaps each of the theories
mentioned in Chapters
contributes a little to the effect of
birth spacing.
In any case, the important
points are that we know that
poor birth spacing is dangerous
to children’s health, and we
know what to do about it:
Make this information known
to parents and policymakers.
Make family planning
services easily accessible to
everyone who wants to use
them.
35
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