1966-75 37 1976-85 b/
Number Exposed IMR (lqO) Number Exposed IMR(lqO) %
Variables of deaths births /1000 of death births /1000 change
Cohort bom
1966-70 A 737 4639 159
1971-75 B 749 5101 147
1976-80 C 437 4467 98 -38**A,C
1981-85 D 416 4840 86 -42**B,D
Sex of the child
Male 766 4931 155 459 4812 95 -38**
Female 720 4809 150 394 4495 88 -42**
Maternal age at childbirth (years) < 24 700 4002 175 420 4204 100 -43** 24-33 567 4158 136 343 3991 86 -37** 34 + 219 1580 139 88 1095 80 -42** Birth order 1 354 2098 169 188 2031 93 -45** 2-3 499 3487 143 311 3580 87 -39** 4-5 322 2275 142 195 2156 90 -36** 6 + 269 1559 173 146 1473 99 -43** Length of preceding c/ birth interval (months)
< 19 280 1186 236 126 932 135 -43**
19-36 619 4059 152 355 3811 93 -39**
37 + 232 2515 92 147 2375 62 -33**
Overall 1486 9740 153 853 9307 92 -40**
Notes: 37 denotes results based on 1976 NFS data and b7 denotes results based on 1986 NFFS data.
j|c j|c # ^ t
indicates significant at the 1 per cent level in the test o f difference in two proportions. Figures may not tally to 100 per cent because of the missing cases. c7 indicates only second and higher order births.
The results from both surveys have established a negative association between the
length of preceding birth interval and survival status of index infant. This result
contradicts the findings of other research which has found a stabilised U-shaped relationship between these two variables. An adverse influence of short birth interval on infant mortality could be due to the maternal depletion syndrome caused by a rapid succession of pregnancies and/or childbirths which in turn could have resulted in low birth weight affecting the growth as well as survival of the index child. The observed marked decline in death rates for infants bom under 19 months of interval during the period 1966 - 1985, on the other hand, to some extent could be the effect of the decline in the proportion of births in this category in the later survey compared with the preceding survey27. The declining risk of death with the increase in length of interval, which suggests better survival prospects for those born after a longer interval, could be due to adequate time for mothers to recover from the previous pregnancy and breastfeeding before their next conception. Moreover, this also explains the smaller number of children of similar ages for these mothers which in turn could allow them to provide proper time and resources to the newly bom.
Table 3.2 shows the number of child deaths, the number of children exposed to death and cross-classified child mortality rates according to demographic variables from the 1976 NFS and 1986 NFFS data sets. From both the 1976 NFS and 1986 NFFS, the probability of death corresponding to different cohorts of children, as in infant mortality, suggests a gradual decline in child mortality rates in Nepal for the period 1961 - 1980. The death rate for the cohorts of children born during the period 1976-80 (from the 1986 NFFS) has sharply declined (50 per cent) from the mortality level experienced by the
cohort of children bom during the period 1961-65. This again suggests a marked
improvement in child survival prospects in Nepal during recent decades.
Proportion of births corresponding to less than 19 months, 19-36 months and over 37 months of interval from the 1976 NFS were respectively 15, 52 and 32 per cent while the corresponding proportions from the NFFS were respectively 13, 54 and 33 per cent.
The Table 3.2 confirms the findings of Gubhaju (1991: 103) based on the 1976 NFS data that child mortality was higher for females than for males. As in neighbouring countries, India and Bangladesh, preference for a son in Nepal does exist. In the 1976 NFS, 2,976 women said that they wanted additional children. Of these women 68 per cent indicated preference for a son, 7 per cent for a daughter and 25 per cent no preference for either sex. Similarly, 1,603 women in the 1986 NFFS desired an additional child; of these 63 per cent indicated a son preference, 12 per cent a daughter preference and 25 per cent did not suggest preference for either sex. All these are clear indications of a strong preference for sons among Nepalese women. The preference for sons could be associated partly with old-age security, and partly with religious values (for detail see Stone, 1978 and Levine, 1987). This to some extent could lead to differentials in child care and household resource allocation by sex resulting in a higher female death rate. However, in the multivariate analysis based on both data sets carried out in the later sections of this chapter, the effect of sex of child on child mortality was not statistically significant.
In both surveys maternal age at childbirth and length of preceding birth interval showed a negative association with survival status of children. Thus maternal age at childbirth from these data sets does not confirm the usual U-shaped relationship with child survival observed, for example, in Sri Lanka (Trussell and Hammerslough, 1983: 16) and the Philippines (Martin et al., 1983: 422).
As in the case of infant mortality analysis, closely spaced births show poor child survival prospects compared with births after 36 months of the birth of the preceding child. The adverse effect of a short interval on the survival of the index child could be a result of socio-economic factors such as competition for food and household resources among children. Moreover, the risk of death among those born within a short interval and who survived infancy could have extended to elevated risk throughout their childhood period. Because Nepal is a developing country where the majority of the people are surviving with limited resources, the problem could have been compounded. Those who enjoyed better survival prospects during their infancy due to the longer interval between births are likely to enjoy a better situation in childhood, too. This is because mothers who
have given birth after a longer interval are likely to be responsible for a smaller number of
Nepal.
1961-70 37 1971-80 b/
Exposed CMR (4ql) Exposed CMR(4ql) (%)
Variables Death children /1000 Death children /1000 change
Cohort bom 1961-65 A 305 2663 115 1966-70 B 1971-75 C 393 3902 101 205 2743 75 -35**A,C 1976-80 D 230 4030 57 -43**B,D
Sex of the child
Male 341 3266 104 213 3526 60 -42**
Female 357 3299 108 222 3247 68 -37**
Maternal age at childbirth (years) < 24 287 2705 106 215 3277 66 -38** 24-33 345 3059 113 188 2934 64 -43** 34 + 66 801 82 30 536 56 -32 Birth order 1 144 1541 93 90 1668 54 -42** 2-3 273 2461 111 164 2704 61 -45** 4-5 172 1522 113 107 1518 70 -38** 6 + 94 890 106 70 835 84 -21 Length of preceding c/ birth interval (months)
< 19 79 510 155 48 497 97 -38**
19-36 306 2353 130 198 2484 80 -39**
37 + 131 1888 69 82 1816 45 -35**
Overall 698 6565 106 435 6773 64 -39**
Notes: denotes results based on 1976 NFS data and " denotes results based on 1986 NFFS data. j|c s|c
indicates significant at the 1 per cent level in the test of difference in two proportions. Figures may not tally to 100 per cent because o f the missing cases. indicates only second and higher order children.
Sources: 37 1976 NFS and b/ 1986 NFFS data tape.
Birth order and survival status of child in this study were expected to show the usual U-shaped relationship. However, the 1976 NFS surprisingly shows a reverse U-shaped relationship between birth order and survival status of children, while the 1986 NFFS shows a positive association between these two variables. The relationship between birth order and child mortality is thus not very clear at this level of analysis.
Tables 3.3 and 3.4 show a detailed analysis of infant mortality rates according to birth order and maternal age at childbirth from both surveys after controlling for the effect
of each independent variable on the other. Tables 3.3 and 3.4, in general, show a declining risk of infant death rate with increasing mother's age at childbirth after controlling for the order of births. In general, there is an increasing risk of infant death associated with the increase in the order of birth after controlling for the effect of mother's age at childbirth, except for the births to mothers in the 24-28 year age group. The results in Tables 3.3 and 3.4 also show that women who bore a large number of children at younger ages are more likely to lose their more recent child during infancy. This phenomenon is more pronounced in the 1986 NFFS than in the 1976 NFS (Tables 3.3 and 3.4).
The negative association between mother's age at childbirth and infant mortality after controlling for the effect of birth order in Tables 3.3 and 3.4 and the lower risk of death to infants bom to mothers aged 34 and over noted in the overall column of Table 3.4 has various possible explanations. First, it is widely cited in the literature that older mothers are likely to forget to report births, especially those who died at an early age. Some omission and misreporting by older mothers was noted in the preceding analysis (see Chapter Two). This to some extent could have influenced the result. However, the error due to data can be considered negligible because the results of the analysis based on the most recent birth cohorts in Tables 3.7 and 3.8 do not change the pattem of the relationships observed between the variables of interest. So, the most likely reason here is that frequent births among mothers in early ages are likely to be associated with closely spaced births leading to unfavourable survival status for those bom to younger mothers. In contrast, births to older mothers are likely to be associated with a longer interval (see Appendix Table 3.2.).
In this circumstance the survival of both (preceding and subsequent) siblings is likely to benefit. For example, the earlier birth could have enjoyed a longer duration of breastfeeding while the later could have enjoyed the benefit of mother's good nutritional status before the conception of the next child, due to the longer interval between her children. This situation could have allowed the later child to be bom within the average weight range with no gestational problems which in turn could have exposed it to lower risk of death. Thus the pace of childbearing and the age at delivery are the major
of birth: 1966-75, Nepal.
Maternal Infant mortality rate
age at ---
childbirth Order of births Over-
(years) 1 2 3 4 5 6 all < 19 210 227 213 — — — 214 (805) (256) (47) — — - (1110) 19-23 148 152 167 223 155 — 160 (980) (1005) (600) (238) (58) (2892) 24-28 146 114 137 150 143 212 144 (233) (448) (615) (554) (349) (208) (2407) 29-33 49 86 100 110 128 164 127 (61) (128) (230) (318) (359) (555) (1651) 34 + — 78 47 97 133 167 139 (51) (107) (186) (211) (785) (1359) Overall 169 147 139 146 136 173 153 (2098) (1888) (1599) (1298) (977) (1559) (9419)
Notes: ' indicates less than 30 cases.
Analysis considers children bom between 1966-1975. Figures in parentheses indicate number of cases. Source: 1976 NFS data tape.