Knowledge Brief Health, Nutrition and Population Global Practice EARLY CHILDBIRTH AND UNDER-FIVE MALNUTRITION IN THE DEMOCRATIC REPUBLIC OF CONGO Adenike Onagoruwa and Quentin Wodon June 2017 Child Marriage Series with Education Global Practice KEY MESSAGES:  In the Democratic Republic of Congo, more than four in ten children under the age of five are stunted; but for children born of mothers younger than 18, the risk of stunting is higher.  Controlling for socio-economic and other characteristics, being born of a mother younger than 18 increases the likelihood of stunting for children under-five by seven percentage points in the baseline model, as compared to otherwise similar children born of older mothers. Box 1: Brief and Series Primer Nearly one-fifth of under-five deaths could be prevented with optimal feeding. Poor nutrition at a young age may How is early childbirth defined? Early childbirth is defined in also have irremediable consequences for brain this brief as a child being born of a mother younger than 18. Early development, cognitive skills, and productivity in adult life. childbearing is often related to the practice of child marriage. Malnutrition has severe consequences for children. Why a series on child marriage? Child marriage has significant negative impacts – not only for girls, but also for a range of development outcomes. Demonstrating these impacts will assist Poor nutrition weakens children’s immune systems, putting governments and others to make the case for intervening to them at a greater risk of falling sick from preventable reduce the practice. illnesses such as pneumonia and diarrhea. According to Horton et al. (2008), nearly one-fifth of under-five deaths in What are the topics discussed in the series? The series looks the world could be prevented with optimal feeding. at the impacts of child marriage on health, population, education, Research also suggests that poor nutrition at a young age employment, agency, and violence, among other outcomes. The may have irremediable consequences for brain welfare, budget, and non-monetary costs of child marriage are development, cognitive skills, and ultimately productivity in estimated. Legal/institutional aspects and options to reduce the practice are also discussed. adult life. Unfortunately, a large share of children in the developing world are malnourished. The question What is the question asked in this brief? The question is: What considered in this brief is whether early childbirth (defined is the impact at the margin of an early childbirth on the probability as a child being born of a mother younger than 18), which of malnutrition (stunting) for children under-five years of age? in many countries is the result of child marriage, contributes to under-five malnutrition in a significant way in the How is the question answered? Econometric analysis of Democratic Republic of Congo. The brief is part of a series Demographic and Health Survey data is used to estimate the of similar standardized country-specific briefs on the same impact of an early childbirth on under-five malnutrition. topic for a number of countries. Page 1 HNPGP Knowledge Brief  Statistically, children from young mothers are three marginal impacts in percentage terms. For example, a percentage points more likely to be stunted than if the statistically significant coefficient of 0.05 for a mother mother is between 18 and 34 years of age. younger than 18 would indicate that children of very young mothers have a likelihood of stunting five percentage points The focus in this brief is on stunting as a measure of higher than otherwise similar children of older mothers. persistent exposure to malnutrition with potentially severe long-term consequences throughout a person’s life (see With the baseline specification, table 2 suggests that box 2 on indicators used to measure malnutrition). The deliveries at a young age increase the likelihood of stunting analysis is based on data from the 2013-14 Demographic for the children by 7.2 percentage points in comparison to and Health Survey for the Democratic Republic of Congo. a delivery at 18 to 34 years of age (coefficient statistically Estimates suggest that 45.41 percent of children born of significant at the five percent level). The difference in risk mothers younger than 18 are stunted. The proportion is still of stunting between mothers ages 18-34 and mothers high, but three points lower at 42.44 percent for children above 35 is not statistically significant with the baseline born of mothers 18 to 34 years of age. For children of model. mothers older than 35, the incidence of stunting was still lower at 40.63 percent. Deliveries at a young age may increase the likelihood of stunting for the children by 7.2 percentage points in Table 1: Incidence of Stunting by Age of the Mother comparison to a delivery at 18 to 34 years of age. Age of the mother Stunting (%) Mother younger than 18 45.41 Mother in 18-34 age bracket 42.44 Although the marginal effect for delivery at a young age Mother older than 35 40.63 changes in the extended model, there is evidence that after Source: Authors. controlling for a wide range of variables, early childbirth may contribute to stunting, but prudence remains needed Box 2: Measures of Malnutrition when interpreting these results given the risk of omitted variable bias (see box 3). Three main measures of malnutrition are used in applied work. A child is considered underweight if s/he has a weight more than Table 2: Impact of Early Childbirth on Stunting two standard deviations below the reference median weight for Age at first marriage Baseline Extended the child’s age. A child is considered wasted if s/he has a weight model model to height ratio more than two standard deviations below the Mother younger than 18 0.0721** 0.0376 median weight for height for the reference population. A child is Mother in 18-34 age bracket Reference Reference considered stunted if s/he has a height more than two standard Mother older than 35 -0.0427 -0.0526* deviations below the median reference height for that age. If a Source: Authors. child on any of these measures is below three standard deviations Levels of statistical significance: *** 1%, ** 5%, * 10%. of the norm, s/he is considered as severely underweight, wasted, or stunted. Among the three measures, stunting and wasting tend to be used the most. Stunting often results from persistent Box 3: Risk of Omitted Variable Bias insufficient nutrient intake and infections. It may lead to delayed motor development and poor cognitive skills that can affect school Early childbirth appears to be positively correlated with the risk of performance as well as productivity and earnings later in life. stunting after controlling for other factors that may also contribute Wasting tends to result more from acute food shortage or disease to stunting. This could indicate a causal effect. However, other and may lead to death. For the purpose of this brief, given a variables correlated with both early childbirth and stunting not separate brief of under-five mortality, stunting is the best measure included in the analysis could be at the source of the correlation to focus on. between early childbirth and stunting. Because of the risk of omitted variable bias, the results cannot be considered as fully conclusive regarding a causal impact of early childbirth on the risk Controlling for other factors, early childbirth still of stunting. increases the likelihood of stunting substantially. A number of results from the regression analysis not shown The difference in the likelihood of stunting between children in table 2 are worth mentioning. The impact of wealth on of young and older mothers does not necessarily imply a the likelihood of stunting is statistically significant and large causal effect of the age at delivery, but it does suggest that in the three highest wealth quintiles. For example, children early childbirth may contribute to stunting. To check in the highest quintile (the richest 20% of households) have whether controlling for other factors early childbirth is a likelihood of stunting twenty-two percentage points lower indeed associated at the margin with higher under-five than children in the poorest 20% of households. malnutrition, regression analysis is used (see the annex for details on the methodology). As shown in table 3, the marginal impact of a mother having a secondary education or better on the likelihood that her Table 2 provides key results with baseline and extended child will be stunted is not statistically significant, which is models. The interpretation of the coefficients is in terms of somewhat surprising. Page 2 Note though more generally that the inclusion of education share of children born of mothers younger than 18. Given as a control points to the possibility of indirect effects of the rate of stunting nationally, one in 100 stunted children early childbirth on stunting. Because early childbirth may could be considered as stunted due to the direct effect of have an impact on other variables used as controls in the early childbirth on the likelihood of stunting. This may regression, its overall effect on stunting, including indirect appear low in comparison to the total number of children effects through these other variables, may be larger than who are stunted, but still represents a large number of the direct effect documented in table 2. For example, for children. some girls having a baby at a young age, early childbirth could have reduced education attainment, which could lead Because only a small share of deliveries are by mothers to a higher risk of stunting (although not in the Democratic younger than 18, only one in 100 stunted children can be Republic of Congo according to the regression results). In said to be stunted directly due to early childbirth. addition, early deliveries, by increasing the number of household members may also contribute to lower Conclusion standards of living. In the Democratic Republic of Congo, as mentioned earlier, the regression results suggest that the level of welfare as measured through wealth quintiles Early childbirth contributes to the risk of malnutrition for have an effect on stunting. Still, in terms of magnitude, children, directly and indirectly. This brief has provided estimates of the direct impact of early childbirth on stunting those indirect effects are likely to be small in comparison to in the Democratic Republic of Congo using the latest DHS the direct effects in table 2. survey. More than four in ten children under the age of five are stunted. For children born of mothers younger than 18, Early childbirth may affect under-five malnutrition through the risk of stunting is higher by three percentage points. lower education attainment for mothers or lower socio- Controlling for socio-economic and other characteristics, economic status, but these effects are likely to be smaller. being born of a mother younger than 18 appears to increase the likelihood of stunting by seven percentage Table 3: Impact of the Mother’s Education on Stunting points versus children born of older mothers. Given the Age at first marriage Baseline Extended share of children born of mothers younger than 18, model model nationally for every 100 stunted children, at least one could No education or below primary Reference Reference be stunted directly because of early childbirth. This may Primary education 0.00754 0.0197 appear low, but still represents a large number of children. Secondary education or higher -0.000753 0.0180 Source: Authors. References Levels of statistical significance: *** 1%, ** 5%, * 10%. Fall, C. H., et al., 2015, Association between maternal age at Overall, the results suggest that as a first order childbirth and child and adult outcomes in the offspring: a approximation, one may rely on the estimated direct effects prospective study in five low-income and middle-income countries of early childbirth on stunting when simulating the impact (COHORTS collaboration), Lancet Glob Health 3(7):e366-77. of the elimination of early childbirth on malnutrition in the country. Doing so does likely entail underestimation of the Finlay. J. E., E. Özaltin, and D. Canning, 2011, The association overall effects, but probably not by a wide margin. of maternal age with infant mortality, child anthropometric failure, diarrhoea and anaemia for first births: evidence from 55 low- and Simulations suggest that about one in 100 stunted middle-income countries, BMJ 1:e000226. children is stunted directly due to early childbirth. Horton, S., H. Alderman, and J. Rivera. 2008. “Copenhagen Consensus 2008 Challenge Paper: Hunger and Malnutrition.” The last step in the analysis consists in assessing the http://www.copenhagenconsensus.com. potential impact of eliminating early childbirth on stunting. This is done by predicting (i.e. simulating) the likelihood République Démocratique du Congo, 2014, Deuxième enquête that children who were born of mothers younger than 18 démographique et de santé (EDS-RDC II 2013-2014), Ministère would have been stunted if they had been born of older du Plan et Suivi de la Mise en œuvre de la Révolution de la mothers. In other words, we are considering the direct Modernité, Ministère de la Santé Publique, et MEASURE DHS, effects of the age of the mother on stunting, shifting in the Rockville, MD: ICF International. data deliveries by young mothers to deliveries at a later age, and observing the difference that this makes for stunting rates nationally. The simulations suggest that without early deliveries, the share of children stunted could decrease by about 0.3 percentage points. This corresponds (roughly) to the product of the marginal effect of early deliveries on stunting (0.072 in table 2) times the Page 3 HNPGP Knowledge Brief  Annex: Methodological Note In this brief, due to space constraints and because of the interest in the share of stunting that could be attributed to early childbirth, There is an existing literature on the relationships between early the focus is on reporting results from probit regressions. In those childbirth, child marriage, and the risks of under-five malnutrition regressions, the dependent variable is whether a child is stunted (e.g., Fall et al., 2015, and Finlay et al. 2011). This literature or not. suggests that children born of young mothers are at higher risk of malnutrition. How much higher in the case of Niger is the question Different specifications are estimated to assess the robustness of to be answered. To answer this question, this brief focuses on the results to the choice of models. Overall, the results are fairly stunting as the measure that tends to best capture persistent robust to different specifications. For the baseline model, the exposure to malnutrition with likely long term negative independent variables are the following: (1) the age of the mother consequences for children. at the time of delivery by categories; (2) the child’s age and gender; (3) whether the child had siblings born at the same time There is no doubt that children born to very young mothers are (multiple birth); (4) the birth order of the child and the child’s birth more likely to be malnourished than other children, but this might weight by categories; (5) the length of time between the child’s not specifically be due to the fact that the mothers are young. Girls birth and a previous birth for the mother; (6) whether the child has who have children before the age of 18 tend to be poorer. This received recommended immunizations; (7) whether the delivery implies that their children are at higher risk of inadequate took place in a health facility and was attended by skilled nutritional intake. Early pregnancies are more common in areas personnel; (8) the mother’s height and education level, as well as where access to healthcare is limited to prevent or treat whether she works and the type of work involved; (9) the father’s malnutrition. Young girls also often suffer from a lack of agency occupation and his level of education; (10) the location of the child and decision-making power in the household, which may reduce by region and by urban-rural category; (11) whether the their ability to seek care for their children when needed. Girls who household has access to an improved water source and improved give birth early are likely to have dropped out of school due to sanitation; (12) whether the household has more than two pregnancy or marriage, which may also affects the nutritional children under-five; and finally (13) the wealth quintile of the status of their children due to lack of education or knowledge on household. how to best take care of young children. In the extended model, additional controls are added: (14) These risk factors correlated with early childbirth do not whether the household practices polygyny; (15) whether the necessarily imply that early pregnancies by themselves contribute distance to health facility is a major problem for the household; in a direct way to child malnutrition. Controlling for other factors, (16) the age gap between the spouses; (17) indicators of it could be that early childbirth does not lead to a higher risk of decision-making power for the mother; (19) tolerance towards malnutrition for children. But it could also be that there is a direct wife beating; and (20) whether the mother is able to get causal link between early childbirth and child malnutrition, for permission to access healthcare. example if some young mothers giving birth are not yet be ready physiologically to give birth, which could in turn affect the health of their children. This brief estimates the direct impact of early This brief was produced by a World Bank team as part of the Economic childbirth on under-five malnutrition. Impacts of Child Marriage study. The synthesis report under the study was produced jointly with the International Center for Research on Women. In addition, the brief provides an assessment of the extent to The study benefitted from support from the Bill & Melinda Gates which under-five malnutrition would be reduced if early Foundation, the Children’s Investment Fund Foundation, and the Global pregnancies/deliveries were eliminated. In order to measure the Partnership for Education. Comments from colleagues and peer potential impact of early childbirth at the margin on stunting for reviewers are gratefully acknowledged. The opinions expressed in this children under the age of five, regression analysis is used. In the brief are those of the authors only and need not reflect the views of the World Bank, its Executive Directors, of the countries they represent. more detailed paper on which this brief is based, both tobit regressions (to measure the degree of stunting among children who are stunted) and probit regressions (to measure the likelihood of stunting) are provided. The Health, Nutrition and Population Knowledge Briefs of the World Bank are a quick reference on the essentials of specific HNP-related topics summarizing new findings and information. These may highlight an issue and key interventions proven to be effective in improving health, or disseminate new findings and lessons learned from the regions. For more information on this topic, go to: www.worldbank.org/health. Page 4