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Assessing the Impact of Birth Spacing on Child Health Trajectories

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Assessing the Impact of Birth Spacing on Child Health Trajectories Global Development Policy Center HCI WORKING PAPER 001 • SEPT 2018 HUMAN CAPITAL INITIATIVE Assessing the Impact of Birth Spacing on Child Health Trajectories MAHESH KARRA ABSTRACT We investigate the effect of birth spacing between siblings on child health trajectories and invest- ments using longitudinal data from the Young Lives Study. We analyzed a birth cohort of over 7,000 children with data collected between 2002 and 2013 from four low- and middle-income countries. We found increased height among children who were more widely spaced relative to children who were narrowly spaced (within two years from an older sibling). However, we also found evidence of Mahesh Karra is an Assistant compensatory growth (converging height and HAZ scores) for closely spaced children as they aged. Professor of Global Development There was a positive association between birth spacing and prenatal investments, which suggests Policy at the Frederick S. that the emergence of height gaps could have been driven by parental behavior in addition to bio- Pardee School of Global Studies logical factors. However, we found little evidence that compensatory growth was driven by remedial at Boston University and health investments in closely spaced children after birth, suggesting catch-up growth as a biological Associate Director of the Human phenomenon. Available data suggests financial constraints and caregiver perceptions of child health Capital Initiative at the Global Development Policy Center. as possible explanations for lack of remedial investments. Keywords: birth spacing, health, nutrition, child investments, compensatory growth, height HCI@GDPCenter www.bu.edu/gdp Pardee School of Global Studies/Boston University 1 Introduction The importance of birth spacing for maternal and child health has been a long-standing source of interest to researchers and policymakers (World Health Organization, 2005). Evidence from systematic reviews and other empirical studies have suggested that short birth intervals (less than two years between births) may be associated with increased risk of maternal and child mortality and morbidity (Conde-Agudelo et al., 2006). These increased morbidity risks in childhood may, in turn, lead to lower educational attain- ment (Oreopoulos et al., 2008), poor labor market outcomes (Smith, 2009; Case et al., 2005), lower human capital and social status (Case et al., 2001), and lower earnings in adulthood (Case et al., 2005; Schultz, 2002). Examined morbidity risks have primar- ily concerned birth and early life outcomes including pregnancy-related complications (high blood pressure, pre-eclampsia), preterm birth, low birthweight, and small for gestational age. However, the evidence of birth spacing effects on downstream child morbidity and health outcomes is scant and either weak or mixed (Dewey and Cohen, 2007). To our knowledge, no studies have investigated whether adverse early life health outcomes associated with short intrapartum spacing persist in older children, especially as they transition into adolescence. In this study, we investigate the effect of birth spacing between siblings on child health outcomes (height and height-for-age) using longitudinal data that was collected on a cohort of children and their siblings in four low- and middle-income countries. As part of our analysis, we assessed whether the estimated impact of short intrapartum spacing changed for the sample as children aged. We also investigated potential mech- anisms behind observed patterns by examining the relationship between birth spacing and parental investments in child health from conception to early adolescence. 2 Background The relationship between short proceeding birth interval and high infant and child mortality is well established in a wide range of populations (DaVanzo et al., 2004). Conversely, there is little empirical evidence that directly assesses the links between birth intervals and child morbidity, which is surprising considering that the mecha- nisms through which birth intervals may influence child health and well-being have been extensively discussed in the literature (DaVanzo et al., 1983; Miller, 1991). In particular, the consequences of a short birth interval for child health outcomes, partic- 2 HCI@GDPCenter 2 www.bu.edu/gdp Pardee School of Global Studies/Boston University ularly at younger ages, have often been attributed to the physiological effects related to the “maternal depletion syndrome,” which postulates that the woman may not have fully recuperated from one pregnancy before supporting the next one (Conde-Agudelo et al., 2012; Dewey and Cohen, 2007). Other mechanisms that have been hypothe- sized to contribute to a detrimental effect of a short preceding interval include: 1) behavioral effects that are associated with competition between siblings, which may include competition for parental time or resources; 2) depleted parental investments or household resources that were used for the earlier birth, which may include a lack of physical resources or even a psychological or emotional inability to provide the later child with adequate attention if its birth came sooner than desired; and 3) larger mor- bidities through higher disease transmission among closely spaced siblings, particularly at younger ages (DaVanzo et al., 2004; Conde-Agudelo et al., 2012). The closest approximation of child morbidity effects from birth spacing is provided by studies that examine the relationship between indicators of childhood malnutrition (stunting, wasting, underweight) and family formation patterns. A systematic review by Dewey and Cohen (2007) assessed the evidence from 52 studies and noted that approximately half found that a previous birth interval of at least 36 months was associated with a 10 to 50 percent reduction in childhood stunting (similar for wasting), whereas the remaining studies found no association or were inconclusive. A more recent study by Fink et al. (2014), which pooled 153 Demographic and Health Surveys (DHS) surveys across 61 countries conducted between 1990 and 2011, found that birth intervals of less than 12 months and between 12 and 23 months were associated with higher risks for stunting (relative risks of 1.09 and 1.06) as compared to a 24 to 35 month inter-pregnancy interval. Due to the cross-sectional nature of the data, however, Fink et al. (2014) were limited in their ability to make inferences on the persistence of these associations in children over time. Our study aims to address the shortcomings in the literature in two ways. First, we improve on prior methodologies that have almost exclusively relied on cross-sectional data by exploiting a longitudinal dataset that allowed us to observe changes in birth spacing effects over stages of child development. Importantly, the cross-sectional struc- ture of the DHS does not allow one to adequately control for birth cohort effects when examining health trajectories over childhood. Moreover, the DHS does not include height measures for children after age 5. Second, we explore the biological and be- havioral mechanisms driving results by examining parental investment patterns on the 3 HCI@GDPCenter www.bu.edu/gdp 3 Pardee School of Global Studies/Boston University basis of birth spacing. 3 Data and Methods 3.1 Data For our analysis, we used longitudinal data from the Young Lives Study (YLS), which investigates the determinants of childhood poverty and well-being (Oxford Depart- ment of International Development, 2017). As part of the YLS, data was collected on a cohort of children born between 2001 and 2002 from four low- and middle-income countries—Ethiopia, India, Peru, and Vietnam. The sampling design included select- ing 20 communities in each country and randomly selecting 100 children from each. We used data available on approximately 8,000 children (2,000 from each country) over four survey waves that were conducted in 2002, 2006, 2009, and 2013, when children were approximately 1, 5, 8, and 12 years old. The study also collected information on household and child characteristics in each survey wave, including the anthropomet- ric markers height and weight. Beginning in the third survey wave, anthropometric markers were also collected for a sibling of the primary cohort of children. We derived birth spacing by combining the household rosters collected during each wave of the survey. Date of birth was collected directly for the primary cohort and for siblings with anthropometric data. For the remaining siblings who were reported on the household rosters, reported age in years was combined with the date of interview to calculate an approximate date of birth. For those with an older sibling, we grouped spacing to next oldest sibling into four categories: spaced under 2 years, spaced 2 to 3 years apart, spaced 3 to 7 years apart, and spaced 7 years or more apart. A number of household and child characteristics were also used in analyses to help control for demographic and socioeconomic effects on child health outcomes (see Appendix B for outcome and control variable construction details). The YLS consists of a total of 31,366 observations for the primary cohort of children summed across the four survey waves and four countries in the study. Of this sample, we dropped 0.3 percent of observations due to missing data on birth spacing and another 5.6 percent due to missing household or child characteristics (including height). This left us with a panel sample of 29,505 observations from 7,480 children born between 2001 and 2002. 4 HCI@GDPCenter 4 www.bu.edu/gdp
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