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Paul Welaga Cornelius Debpuur Cornelius Debpuur Timothy Awine 10 th INDEPTH AGM 27 th -30 th September 2010 Accra Background Evidence on the relationship between birth-spacing and child survival is still not clear Recommendations for


  1. Paul Welaga Cornelius Debpuur Cornelius Debpuur Timothy Awine 10 th INDEPTH AGM 27 th -30 th September 2010 Accra

  2. Background � Evidence on the relationship between birth-spacing and child survival is still not clear � Recommendations for birth spacing are based on information that was available several years ago (WHO Technical report on birth spacing, 2005) � Some publications recommend waiting at least 2–3 years between pregnancies to reduce infant and child mortality � Recent studies suggested that longer birth spacing, 3 to 5 years might be more advantageous to child survival ( S. O. Rutstein, 2005)

  3. Objectives � To compare infant mortality rates between index children with preceding birth interval of 3 to 5 and 2 to 3 years � To examine differences in neonatal mortality rates between index children with preceding birth interval of 3 to 5 and 2 to 3 years � To examine differences in under two mortality rates between � To examine differences in under two mortality rates between index children with preceding birth interval of 3 to 5 and 2 to 3 years � To examine differences in under-five mortality rates between index children with preceding birth interval of 3 to 5 and 2 to 3 years

  4. Methods � Children of second or higher order singleton live birth (index children) born in the DSS area between 1 st January 2002 to 31 st December 2007. � Preceding birth was defined as the difference in months between the birthdates of the index and immediately preceding child � Preceding birth interval was categorised into four groups; <24, 24-35, 36-59, and 60+ months � All children registered into the system were taken into account in calculating preceding birth interval

  5. Data � Data for the analysis come from the Navrongo Health and Demographic Surveillance System (NHDSS) � NHDSS monitors a population of about 150,000 under surveillance � � Demographic events such as births, deaths, in and out migrations, pregnancies are updated every three months � NHDSS also collects data on vaccination, education, verbal autopsy and socioeconomic status

  6. Study setting – Fertility trends TFR 6.00 5.00 4.00 3.00 TFR 2.00 1.00 0.00 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

  7. Analysis � To examine the effect of preceding birth interval on post- neonatal, infant and under-five mortality, Cox proportional regression models were used. � Logistic regression models were used to assess the effect on neonatal mortality. � Mortality rates were expressed per 1000 live births for neonatal � Mortality rates were expressed per 1000 live births for neonatal mortality and per 1000 child years of risk for post-neonatal, infant and under-five mortality � Potential confounders controlled for: mother’s age at birth, season of birth, mother’s education, place of delivery, socioeconomic status using wealth index, survival status of immediately preceding sibling, sex, year of birth and birth order

  8. Results � In all 15424 under-five children born between 1 st January 2002 and 31 st December 2007 were included in the analysis � 1,272 deaths were recorded � Infant mortality rate of 63.4 per 1000 person years

  9. Background Characteristics Variable N (%) deaths (% dead) Preceding birth interval 82 (9.2) <24 months 888 (5.8) 287 (9.1) 24-35 3,168 (20.5) 621 (7.9) 36-59 7,894 (51.2) 282 (8.1) 60+ 3,475 (22.5) Sex 587 (7.7) Female 7,637 (49.5) 685 (8.8) Male 7,787 (50.5) Mother’s age at birth 27 (8.0) <20 338 (2.2) 488 (7.4) 20-29 6,637 (43.0) 554 (8.8) 30-39 6,315 (40.9) 203 (9.5) 40-49 2,134 (13.8) Mother’s education 853 (8.7) No education 9,855 (63.9) 281 (6.9) Primary/JSS 4,050 (26.3) 19 (3.9) Secondary+ 493 (3.2) 119 (11.6) Missing 1,026 (6.7)

  10. Relative risk for univariate and multivariate models for under two mortality by preceding birth interval Univariate model Multivariate model Varaible OR [95% CI] P-value OR [95% CI] P-value (unadjusted) (adjusted) Preceding birth interval 1.27 [1.0 – 1.61] 0.053 1.25 [0.97 – 1.63] 0.089 < 24 months 1.18 [1.02 – 1.37] 0.029 1.18 [1.01 – 1.38] 0.039 24-35 24-35 1 1 1 1 36-59* 1.07 [0.92 – 1.24] 0.403 1.09 [0.93 – 1.30] 0.266 60+ Mother’s education None* 1 1 Primary/Junior Sec 0.80 [0.69 – 0.93] 0.003 0.78 [0.67 – 0.92] 0.003 Secondary+ 0.50 [0.31 – 0.79] 0.003 0.48 [0.29 – 0.78] 0.003 missing 1.49 [1.22 – 1.83] <0.001 1.21 [0.97 – 1.52] 0.094

  11. Relative risk for univariate and multivariate models for infant mortality by preceding birth interval Univariate model Multivariate model Varaible P-value P-value HR [95% CI] HR [95% CI] (unadjusted) (adjusted) Preceding birth interval 1.32 [1.01 – 1.74] 0.043 1.29 [0.97 - 1.72] 0.078 < 24 months 1.18 [1.00 – 1.40] 0.057 1.17 [0.98 – 1.40] 0.092 24-35 1 1 - 36-59* 36-59* 1.11 [0.93 -1.31] 1.11 [0.93 -1.31] 0.241 0.241 1.12 [0.92 – 1.35] 1.12 [0.92 – 1.35] 0.257 0.257 60+ Mother’s education None* 1 1 Primary/Junior Sec 0.79 [0.67 – 0.93] 0.005 0.76 [0.63 – 0.91] 0.004 Secondary+ 0.61 [0.37 – 0.98] 0.042 0.55 [0.33 – 0.92] 0.022 missing 1.60 [1.28 – 2.00] <0.001 1.24 [0.97 – 1.58] 0.084

  12. Relative risk for univariate and multivariate models for post neonatal mortality by preceding birth interval Univariate model Multivariate model Varaible P-value P-value HR [95% CI] HR [95% CI] (unadjusted) (adjusted) Preceding birth interval 1.43 [1.03 – 1.99] 0.034 1.41 [0.99 – 2.01] 0.055 1.45 [1.17 – 1.78] 0.001 < 24 months 1.47 [1.20 – 1.80] <0.001 24-35 1 1 36-59* 1.17 [0.95 -1.44] 0.151 1.21 [0.96 – 1.53] 0.100 60+ Mother’s education None* 1 1 Primary/Junior Sec 0.78 [0.63 – 0.95] 0.016 0.74 [0.60 – 0.92] 0.008 Secondary+ 0.59 [0.32 – 1.07] 0.080 0.54 [0.29 – 1.00] 0.051 missing 1.75 [1.35 – 2.28] <0.001 1.38 [1.04 – 1.83] 0.027

  13. Odds Ratio for univariate and multivariate models for neonatal mortality by preceding birth interval Univariate model Multivariate model Varaible OR [95% CI] P-value OR [95% CI] P-value (unadjusted) (adjusted) Preceding birth interval < 24 months 1.13 [0.70 – 1.83] 0.620 1.1 [0.65 – 1.85] 0.720 24-35 24-35 0.69 [0.49 – 0.98] 0.69 [0.49 – 0.98] 0.037 0.037 0.69 [0.48 – 1.01] 0.69 [0.48 – 1.01] 0.054 0.054 36-59* 1 0.996 1 60+ 1.0 [0.75 -1.34] 0.93[0.66-1.30] 0.660 Mother’s education None* 1 0.173 1 Primary/Junior Sec 0.82 [0.61 – 1.09] 0.298 0.81 [0.58 – 1.13] 0.222 Secondary+ 0.65 [0.29 – 1.47] 0.202 0.57 [0.23 – 1.41] 0.220 missing 1.32 [0.86 – 2.01] 1.02 [0.62 – 1.67] 0.941

  14. Relative risk for univariate and multivariate models for under- five mortality by preceding birth interval Univariate model Multivariate model Varaible N (%) P-value HR [95% CI] HR [95% CI] (unadjusted) (adjusted) Preceding birth interval 888 (5.8) 1.17 [0.93 – 1.48] 1.23 [0.96 – 1.58] 0.096 < 24 months 3,168 (20.5) 1.19 [1.03 – 1.36] 1.17 [1.01 – 1.36] 0.038 24-35 7,893 (51.2) 1 1 36-59* 3,475 (22.5) 1.05 [0.91 -1.21] 1.02 [0.88 – 1.18] 0.809 60+ Mother’s education None* 9,855 (63.9) 1 1 Primary/Junior Sec 4,050 (26.3) 0.83 [0.72 – 0.94] 0.78 [0.67 – 0.90] 0.001 Secondary+ 493 (3.2) 0.47 [0.30 – 0.74] 0.40 [0.25 – 0.64] <0.001 missing 2,134 (13.8) 1.47 [1.22 – 1.78] 1.24 [1.01 – 1.52] 0.045

  15. Discussion and Conclusion � Children with preceding birth interval of 24 to 35 months had a higher risk of dying at infancy, post neonatal, under two and under five compared to 36 to 59 months � Preceding birth interval did not significantly affect neonatal mortality rates. neonatal mortality rates. � The beneficial effect of longer birth spacing becomes evident after the neonatal stage �

  16. Discussion and Conclusion � Birth interval of <24 months is generally associated with a higher risk of dying compared to 36 to 59 months � Mother’s education contributes significantly in � Mother’s education contributes significantly in reducing child mortality

  17. Recommendation � Generally, preceding birth interval of 36 to 59 months should be encouraged as it appears to be beneficial to child survival � Reducing births associated with preceding birth interval of <24 months could help reduce child mortality .

  18. Limitations � The HDSS may not have covered a complete birth history for each woman. This however may form a minority of births for any individual woman and should not undermine the validity of the outcome

  19. Acknowledgement � The chiefs and people of the Kassena-Nankana East and West districts � The director and staff of the Navrongo Health Research Centre � The Navrongo Health and Demographic Surveillance System field and computing teams � INDEPTH Network

  20. Thank you Thank you

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