The 1976 NFS and 1986 NFFS have collected various information at household and individual levels. For example, the information on size of operational land-holding and possession of cows and buffalo are collected at the household level while the characteristics of individuals such as education, work status and literacy are collected at the individual level. Both the 1976 NFS and 1986 NFFS have covered a wide range of variables. Of these, this study employs five socio-economic^ variables: mother's education, father's education, mother's work status, ever use of contraception and place of residence from the 1976 NFS. There were eight socio-economic variables studied from the 1986 NFFS: mother's education, father's education, mother's work status, ever use of contraception, place of residence, size of operational land-holding, number of cows and buffalo possessed by a household, and health care services. However, in the multivariate analysis place of residence and health care variables from the 1986 NFFS were combined because all siblings from urban areas had access to health care services.
The literacy status variable for both the father and mother includes the individual's ability to either read a simple letter in Nepali or write his/her name, while education indicates the highest grade completed by an individual under a formal education institution. The data based on both surveys used in this study suggest that there are also people who are literate but have never been to school. The groups of people who have never been to school but are literate are more likely to belong to a household with a better economic situation. This is because better economic status could enable them to afford education at home. Thus the risk of death for the children of these people is likely to be different from the risk for those who are illiterate or literate with some experience of schooling. So, 1/ Use of contraceptives from the 1976 NFS and use of contraceptives and health care services
from the 1986 NFFS, in this chapter, as described in the framework in Chapter Two, are considered as parallel to socio-economic variables.
father's education in this study is categorised into illiterate, literate with no schooling, and literate with some years of schooling. However, due to the small number of women with education, the education of mother is classified into only two categories: no education and some education. Literate mothers with no schooling are combined with the mothers with some education into one category.
It has been noted that women from the middle and high income groups in South Asian countries, generally, do not choose to work (ESCAP, 1987: 1, cited in Selvaratnam, 1987: 11). This also seems to be true in the case of Nepal because the 1981 Census showed that 55 per cent of the females aged 15 years and above were categorised as dependents. Furthermore, the labour force structure in Nepal is overwhelmingly dominated by agriculture. About 96 per cent of the working women in the 1981 Census were reported to be engaged in the primary sector^ with 0.2 per cent in the secondary sector, 3 per cent in the tertiary sector and the rest in the unclassified category (CBS 1987a: 202-224). Generally, women engaged in a primary sector occupation are likely to have fewer years of schooling. The types of work done by these women therefore are likely to be physical in nature and require low skills and thus have low productivity, low wages and consequently low status. Work involving physical exertion is likely to fatigue women at the end of the day. This in turn could worsen both the quality of child care as well as the survival status of children. However, women with education are likely to obtain a white-collar job and are likely to earn more. As an earning member of a household, such women may have a greater say in the household resource allocation. This could enable mothers to afford a child’s health care, food, and other basic needs which in turn could produce favourable survival prospects for children borne by them. However, grouping of women according to nature of the jobs was not possible because of the small number in non-agricultural occupations. The work status of women in this study, thus, is categorised into working and not working where working indicates those involved in gainful employment (cash or in kind) after their marriage.
2/ Primary sector includes agriculture, forestry, hunting and fishing; the secondary sector includes mining, quarrying, manufacturing and construction; and the tertiary sector includes electricity, gas, water, transport, communication and other services (CBS 1987a: 224).
Since family members living in a house have to share all events that occur in the house, the household economy can be expected to influence child survival. The economy of Nepal is predominantly based on agriculture where about 90 per cent of the people earn their livelihood. This sector thus is characterised by small farms and small farmers (CBS, 1987a: Viii) where continuous fragmentation in size of land-holding due to the property inheritance from earlier to later generations has further compounded the difficulties of the household economy (Pant, 1987). The other problem is that land distribution is highly skewed. For example, about 51 per cent of the total households in 1981 had holdings of less than half a hectare of land which comprised about 7 per cent of the total cultivated land (CBS, 1987a: lx). The size of land-holding thus could be a good indicator for household economy in explaining child survival prospects in Nepal. This variable is likely to explain child survival through the ability of a household to afford various services and satisfy needs such as food, clothing, health, environment and child care. Size of land-holding for the purpose of this study is categorised into no land-holding, under half a hectare, and half a hectare and above.
Another variable used as an indicator for household income in this study is the number of cows and buffalo possessed by a household. A survey in Nepal (NRB, 1988: 81) noted that 61 per cent of the total rural household income was earned from crops, horticulture and livestock. Households in the hills and mountains of Nepal which own cows and /or buffalo, in general, produce ghee from milk (purified butter used for cooking) for market. This product is accumulated for about six months to one year and is sold in the nearest market (for some people the nearest market could be one to two weeks’ walk). The money from this sale is mostly utilized to purchase basic items such as cloth, salt, cooking oil, spices and other products that are not available in their local market, as needed for the
next six months or a year. Ghee is also produced in the terai area. However, people in the
terai are also likely to earn income by direct sale of milk which is less possible for the people in the hill. Therefore, since cows and buffalo are the sources of milk and milk is one of the sources of household income, this variable is likely to serve as an indicator of household income.
The other possible way in which cow and buffalo milk influences child survival could be through the nutritional status of children. This is because children in a household with cows and /or buffalo can be expected to have access to more nutritious food. Producing ghee is likely to yield more income and can be used to meet a wide range of household requirements in a situation where the majority of the people are living with limited resources; accordingly this mechanism is less likely to explain child survival prospects. However, cows' and buffalo milk as a source of nutritious food could be significant during infancy for those whose mothers are not capable of producing enough breast milk. So part of the effect of the cows and buffalo in the household on infant mortality is likely to be explained through the access to nutritious food. This variable in this study is categorised into: no cows and buffalo, 1-3 cows and/or buffalo, and 3 or more cows and / or buffalo, and will be named 'cows' hereafter.
In this study, ever use of contraception and the access to health posts are employed as an indicator for access to health services. Health care and family planning services in the country are briefly described in the following sections. This will help in explaining the results which are obtained subsequently.
The Government supported family planning programme in Nepal has been operating since 1968 with two broad components: family planning and maternal child health care delivery (MCH). The MCH component aims to provide services to surviving children with the expectation of building positive rapport for the promotion of family planning among clients (CBS, 1987a: 318-319). A similar approach to family planning policy was also adopted in Guatemala, Ecuador, Mexico and Peru (Isaacs and Fincancioglu, 1989: 104). By 1985, there were four institutions in Nepal: the Family Planning and Maternal Child Health Project and the Integrated Community Health Development Project, both with Government support; the Family Planning Association^, a non-governmental organization and the Contraceptive Retail Sales (CRS) company, that were involved in family planning 3/ The Nepal Family Planning Association was established in 1958. During its initial period it
served in the Kathmandu valley by providing knowledge and information on family planning. Since the data used in this study cover only up to 1985, change in the health institutions and /or health care delivery after this period is not covered in the discussion.
service delivery. Except for the CRS company, all establishments were involved in delivering family planning services in conjunction with maternal and child health care delivery, health education, nutritional education and environmental health care. The concept of the village health worker, designed to provide door to door services for those who do not want to come to district headquarters for the family planning and MCH services has emerged since 1972. Village health workers were assigned a variety of jobs such as distribution of condoms, pills, motivating clients for sterilization, immunisation of children (limited only), distribution of R-D SOL (oral rehydration solution) and iron tablets to mothers, education about sanitary hygiene and referral of sick children to health posts, health centres or hospital.
The Ministry of Health embarked on establishing health posts in different parts of the country in 1966/67 with the objective of providing basic health service to a maximum number of people. Two types of health posts, 'primary integration' and 'full integration', were designated. The primary integration type was used in distribution of pills, condoms, motivating clients for sterilization, nutritional monitoring, education about health, nutrition, rehydration, environmental health, immunisation and treatment of common illness. Fully integrated health posts, on the other hand, delivered additional services: antenatal, delivery and post-natal services (for further detail see CBS, 1987a: 318-322; Tuladhar and Stockel,
1982: 275-276).
How far can family planning services delivered through family planning institutions and health institutions explain child survival prospects? If they can explain some of the differentials in child survival prospects, the next question is whether the differentials are due to the use of contraception or to the health services delivered in conjunction with family planning services. Unfortunately, this issue in the context of Nepal is neglected. Past studies (Tuladhar, 1987; Schuler and Goldstein, 1986; Ross et al., 1986; Thapa, 1989) in Nepal have mostly used information on family planning services in examining fertility, averted births, unmet need or service accessibility to contraceptors. In this respect, Potter, in reference to the paper of Palloni and Millman (1986), suggested that
mother's use of modem maternal health care is correlated with both breastfeeding and contraceptive use, that contraceptive use is inversely associated with both the initiation and the continuation of breastfeeding, and that contraception rather than breastfeeding has the dominant influence on the length of birth intervals. If in addition to these relationships, it were also true that access to and demand for maternal and child health care influenced infant and child mortality, several of the most relevant conclusions reached by Palloni and Millman would seem to be suspect (Potter, 1988: 447).
The way in which family planning services exert their influence on child survival is centred on the reproductive behaviour of a woman which is expected to change after contraceptive use. In this context Chen et al. (1983: 203) suggested that contraceptive use influences child survival through change in population age structure and alteration in the composition of births. Similarly, Trussed and Pebley (1984: 267) and Palloni and Pinto (1989: 363) argued that family planning reduces the births with high risk of death through changing the birth distribution by age of mother, birth order and inter-pregnancy interval. Potter in this respect argues that,
Since contraception is surely the most important proximate determinant of interval length, not only in the Latin America and Caribbean surveys studied by Palloni and Millman, but also in many of the other surveys that were undertaken by the WFS, this association raises the question of whether it is health care rather than birth spacing that is, in reality, the major determinant of infant and child mortality (Potter, 1988: 448).
Effective practice of contraception, in theory, can be expected to reduce the proportion of births exposed to a higher risk of death by altering the reproductive behaviour of a woman. However, social scientists should not forget the socio-cultural values, norms and practices of the society in question. For example, of the total sampled women, 3.7 per cent from the 1976 NFS and 15.8 per cent from the 1986 NFFS reported themselves as ever users of contraceptives. Of those who have ever used contraceptives, 41 per cent from the 1976 NFS and 71 per cent from the 1986 NFFS were sterilization acceptors. These figures indicate that the role of contraceptive use in influencing child survival through length of birth interval is likely to be negligible. Moreover, a society guided by large family norms where elders bless the young invoking the wish ’may your children spread all over the hills and foothills' further suggests that the child survival differential captured by contraceptive use is less likely to be explained through spacing between siblings' births as a consequence
of contraceptive use. If this4/ is the case, the most plausible explanation of how contraceptive use affects child survival in Nepal can be the MCH component delivered in conjunction with family planning services rather than through birth spacing.
On the basis of the discussion in this section, considering the contraceptive use pattern in Nepal, and on the assumption that those who have ever used contraceptives are also likely to use health services delivered through the same facility, 'ever used contraceptives' in this study is used as the indicator for the utilization of health care services. This variable is categorised as ' never used contraceptives' and 'ever used
contraceptives'. However, as the preceding birth interval emerged as the important
determinant of child survival (Chapter Three), how far contraceptive use in Nepal enabled couples to lengthen their inter-pregnancy interval will also be examined in brief. This part of the analysis will further clarify whether contraceptive use is operating through health care utilization or through birth spacing in explaining child survival in Nepal.
In this study health posts, in the absence of other information on health utilization aspects, are used as an indicator for the health care programme and its utilization. This variable in this study is named 'health care' and is created by using the information on health posts by place and date of establishment published by His Majesty's Government of Nepal (1986). This document covers a complete list of health posts established in Nepal until 1985. There has been substantial growth in the number of health posts. By the year 1970/71, 150 health posts delivered basic health services to the people, increasing to 538 by the year 1979/80 (His Majesty's Government (HMG), 1986: 1-10). This indicates a 286 per cent growth in the number of health posts over 10 years. For the purpose of this study,
first of all the sampled panchayat which have health posts and which do not have health
posts were listed separately. Then, those children who were bom after the establishment of the health posts were categorised as children 'having access to health services' and the rest
4/ Alan Gray argued that contraceptive use should never be used in an explanatory role for