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Background: There is ample evidence of associations between short birth interval and adverse maternal and child health outcomes, including infant and maternal mortality. Short birth interval is more common among women in low- and middle-income countries. Identifying actionable aspects of short birth interval is necessary to address the problem. To our knowledge, this is the first systematic review to systematize evidence on risk factors for short birth interval in low- and middle-income countries., Methods: A systematic mixed studies review searched PubMed, Embase, LILACS, and Popline databases for empirical studies on the topic. We included documents in English, Spanish, French, Italian, and Portuguese, without date restriction. Two independent reviewers screened the articles and extracted the data. We used the Mixed Methods Appraisal Tool to conduct a quality appraisal of the included studies. To accommodate variable definition of factors and outcomes, we present only a narrative synthesis of the findings., Results: Forty-three of an initial 2802 documents met inclusion criteria, 30 of them observational studies and 14 published after 2010. Twenty-one studies came from Africa, 18 from Asia, and four from Latin America. Thirty-two reported quantitative studies (16 studies reported odds ratio or relative risk, 16 studies reported hazard ratio), 10 qualitative studies, and one a mixed-methods study. Studies most commonly explored education and age of the mother, previous pregnancy outcome, breastfeeding, contraception, socioeconomic level, parity, and sex of the preceding child. For most factors, studies reported both positive and negative associations with short birth interval. Shorter breastfeeding and female sex of the previous child were the only factors consistently associated with short birth interval. The quantitative and qualitative studies reported largely non-overlapping results., Conclusions: Promotion of breastfeeding could help to reduce short birth interval and has many other benefits. Addressing the preference for a male child is complex and a longer-term challenge. Future quantitative research could examine associations between birth interval and factors reported in qualitative studies, use longitudinal and experimental designs, ensure consistency in outcome and exposure definitions, and include Latin American countries., Trial Registration: Prospectively registered on PROSPERO (International Prospective Register for Systematic Reviews) under registration number CRD42018117654.

Background: Pre-lacteal feeding has continued as a deep-rooted nutritional malpractice in developing countries. Pre-lacteal feeding is a barrier to the implementation of optimal breastfeeding practices and increases the risk of neonatal early-life diseases and mortality. Therefore, the aim of this study was to assess pre-lacteal feeding practice and associated factors among mothers having children less than 2 years of age in Aksum town, central Tigray, Ethiopia., Methods: A community-based cross-sectional study was conducted to interview 477 mother-child pairs by systematic random sampling technique. Data were collected through interviewer-administered semi-structured questionnaires. Data were coded, entered, cleaned and edited using EPIDATA version 3.1 and export to SPSS Version 22.0 for analysis. To identify the significant variables binary logistic regression were employed. Variables with p-value < 0.05 at 95% CI in multivariate logistic regression were considered statistically significant., Result: The prevalence of pre-lacteal feeding in Aksum town was 10.1% (95% CI: 7.3%, 13%). Mothers with no previous birth (AOR: 2.93(95% CI:1.21,7.09)), birth spacing less than 24 (AOR: 2.88(95% CI: 1.15,7.25)), colostrum discarding (AOR: 6.72 (95% CI: 2.49,18.12)), less than four anti natal care follow up (AOR: 10.55 (95% CI: 4.78,23.40)), those who underwent cesarean section (AOR: 4.38 (95% CI:1.72,11.12)) and maternal believe on purported advantage of pre-lacteal feeding (AOR: 3.36 (95%CI: 1.62,6.96)) were more likely to practice pre-lacteal feeding to their infants., Conclusions: Pre-lacteal feeding is still practiced in the study area. Childbirth spacing, colostrum discarding, antenatal Care follow up, maternal belief in pre-lacteal feeding was contributing factors for practicing of pre-lacteal feeding. Coordination and sustaining the existing strategies and approaches are recommended to give emphasis on the nutritional value of colostrum and anti-natal care follow up.

Over 2 million abortions occur annually in Pakistan, mostly in a clandestine and unsafe environment. This is an area of grave concern for the reproductive health of women. A dearth of credible data and incomplete information make the problem more difficult to address. This qualitative study was conducted in semi-urban settings in Pakistan to record perceptions and practices concerning care seeking, experiences and outcomes regarding induced abortions and post-abortion care services. Women who had had induced abortions and abortion service providers were interviewed. Unwanted pregnancies and poverty were found to be the main reasons for seeking an abortion. Moreover, the unwanted pregnancies occurred due to low use of contraceptives, mainly due to a fear or past experience of their side-effects, unfamiliarity with correct usage and perceived inefficacy of the methods, especially condoms. There is an obvious need for practical and innovative interventions to address unmet need for birth spacing through improved access to contraceptives. Contraceptive providers should be provided with up-to-date and detailed training in family planning counselling, and perhaps allowed unrestricted provision of contraceptives. As a long-term measure, improvement in access to education and formal schooling could increase young girls' and women's knowledge of the benefits of family planning and the risks of unsafe abortion practices. Males must be involved in all the initiatives so that both partners are in agreement on correct and consistent contraceptive use.

During the past two decades, estimates of unmet need have become an influential measure for assessing population policies and programs. This article recounts the evolution of the concept of unmet need, describes how demographic survey data have been used to generate estimates of its prevalence, and tests the sensitivity of these estimates to various assumptions in the unmet need algorithm. The algorithm uses a complex set of assumptions to identify women: who are sexually active, who are infecund, whose most recent pregnancy was unwanted, who wish to postpone their next birth, and who are postpartum amenorrheic. The sensitivity tests suggest that defensible alternative criteria for identifying four out of five of these subgroups of women would increase the estimated prevalence of unmet need. The exception is identification of married women who are sexually active; more accurate measurement of this subgroup would reduce the estimated prevalence of unmet need in most settings., (© 2013 The Population Council, Inc.)

Background: Low birth weight deliveries are major causes of a huge health burden on poor economies around the globe. It is even more worrisome in developing countries., Materials and Methods: The obstetric records of all low birth weight (LBW) deliveries were reviewed from 1 st June 2005 to 30 th May 2009., Results: The prevalence of LBW deliveries was 8.3%. Of the LBW babies, 68.4% were preterm, 53.6% were small for gestational age (SGA) and 12.6% were products of multiple gestations. Predominant factors associated with LBW delivery included nulliparity, low parities (1 and 2), parturient aged 25-35 years (80.6%), hypertensive disorders of pregnancy, and short birth spacing (84.4%)., Conclusion: Most LBW babies were preterm delivered by low parity parturient aged 25-35 years with short inter-pregnancy intervals. Effective family planning and antenatal services provided particularly for these categories of potential parturient could help to curb the incidence.

Globally, about 20 million infants are born with low birth weight (LBW; <2500 g). Of all LBW infants, approximately 95% are born in developing countries. The greatest incidence of LBW occurs in South-Central Asia; the second greatest is in Africa. The two main reasons for LBW are preterm birth (<37 weeks) and intrauterine growth restriction (IUGR), which are risk factors for increased morbidity and mortality in newborn infants. Maternal nutrition status is one of the most important risk factors for LBW/IUGR. Providing balanced protein energy and multiple micronutrient supplements to pregnant women will reduce incidence of IUGR. Calcium supplementation during pregnancy will reduce the incidence of pre-eclampsia and preterm birth in developing countries. Exclusive breastfeeding is protective for a mother and her infant and has been shown to reduce morbidity and mortality in infancy. Kangaroo mother care for preterm infants will reduce severe morbidity and mortality as well. Community-based intervention packages are among the most effective methods of reducing morbidity and mortality in mothers and children. Future research should focus on improving triage of preterm and IUGR infants. Exclusive breastfeeding should be promoted, and appropriate alternative food supplements should be provided when breastfeeding is not possible., (Copyright © 2013 Mosby, Inc. All rights reserved.)

Background: Several birth characteristics are associated with high mortality risk: very young or old mothers, short birth intervals and high birth order. One justification for family planning programs is the health benefits associated with better spacing and timing of births. This study examines the extent to which the prevalence of these risk factors changes as a country transitions from high to low fertility., Methods: We use data from 194 national surveys to examine both cross section and within-country variation in these risk factors as they relate to the total fertility rate., Results: Declines in the total fertility rate are associated with large declines in the proportion of high order births, those to mothers over the age of 34 and those with multiple risk factors; as well as to increasing proportions of first order births. There is little change in the proportion of births with short birth intervals except in sub-Saharan Africa. The use of family planning is strongly associated with fertility declines., Conclusions: The proportion of second and higher order births with demographic risk factors declines substantially as fertility declines. This creates a potential for reducing child mortality rates. Some of the reduction comes from modifying the birth interval distribution or by bringing maternal age at the time of birth into the 'safe' range of 18-35 years, and some comes from the actual elimination of births that would have a high mortality risk (high parity births).

After a decade of fertility decline, Ghana's fertility and the level of unmet need for contraception stalled in mid-transition in the late 1990s. Although the literature acknowledges this, the geographical patterns in unmet need have not been adequately documented. Spatial analysis of unmet need can reveal differences in usage and provision of contraceptive commodities, thereby pointing to geographical areas where contraceptive programmes should be strengthened. This study examines the geographical variation of the risk of mistimed and unwanted pregnancies between rural communities and also between urban communities of the three ecological zones of Ghana. The study also investigates if geographical differences in the risks of mistimed and unwanted pregnancies changed during the period when unmet need stalled at the national level. A multilevel regression model was applied to pooled data from the 1998 and 2003 Ghana Demographic and Health Surveys to examine the determinants of the risk of unintended pregnancies, while controlling for clustering of outcomes within communities. The results show that between the two surveys, there was no significant change in the levels of risk of mistimed and unwanted pregnancy. However, geographical heterogeneity in the risk of mistimed and unwanted pregnancy was observed, after controlling for relevant predictors. This showed concentration of mistimed pregnancies in some rural communities relative to others, and variation in the risk of unwanted pregnancies between urban communities. The results give a clear indication that bridging the inequality gap in contraceptive use requires programmes that are area-specific.

In Lesotho, the risk of mother-to-child-transmission (MTCT) of HIV is substantial; women of childbearing age have a high HIV prevalence rate (26.4%), low knowledge of HIV status and a total fertility rate of 3.5 births per woman. An effective means of preventing MTCT is to reduce unwanted fertility. This paper examines the unmet need for contraception to limit and space births among HIV-positive women in Lesotho aged 15-49 years, using the 2004 Lesotho Demographic and Health Survey. HIV-positive women have their need for contraception unmet in almost one-third of cases, and multivariate analysis reveals this unmet need is most likely amongst the poor and amongst those not approving of family planning. Urgent action is needed to lower the level of unmet need and reduce MTCT. A constructive strategy is to improve access to family planning for all women in Lesotho, irrespective of HIV status, and, more specifically, integrate family planning with MTCT prevention and voluntary counselling and testing services.

Objective: The interval between births is associated with child survival in the developing world. We aimed to investigate associations between use of depot-medroxyprogesterone acetate and other reversible contraception and short birth intervals in sub-Saharan Africa., Methods: Data from successive Demographic and Health Surveys undertaken in nine African countries were analyzed. Logistic regression was used to explain changes in the proportion of short birth intervals in four countries with relatively high use of reversible contraception., Findings: The overall odds ratio for the trend was 0.90 (95% CI 0.84 to 0.95) and this was unaffected by adjusting for the other variables. The odds of a short birth interval were reduced by exclusive breastfeeding (OR 0.67, 95% CI 0.58 to 0.78) and increased by use of injectable contraception (OR 1.23, 95% CI 1.11 to 1.38)., Conclusion: The proportion of short birth intervals has changed little over the last decade in a context of very low use of the intrauterine device. Widespread adoption of injectable contraception is associated with greater odds of a short birth interval, thus not contributing favorable conditions for improved child health.

Objective: To identify the extent of demand for birth spacing, according to age and parity among married women of reproductive age (MWRA) in developing countries., Methods: Secondary analysis of data from the Demographic and Health Surveys (DHS) using cross-tabulations. Data collected from nationally representative samples of MWRA in selected developing countries between 1990 and 2004., Results: Demand for birth spacing is the most prevalent reason for an interest in family planning among married women aged 15-29 years in the majority of developing countries examined. In the 15-19-year age cohort, the demand for spacing is proportionally the most prevalent reason for a demand for family planning. A demand for spacing even exists among young, zero-parity married women in each country examined. Findings on the demand for spacing among zero-parity married women quantifies the expressed desire of some married women in developing countries to postpone a first birth or the timing of a first pregnancy., Conclusion: The substantial demand for birth spacing among young, low- and zero-parity women suggests that family planning programs in developing countries may need to reevaluate how accessible services are for this cohort of potential contraception users. Currently, many service-delivery protocols, counseling practices and service provider training may not fully address the needs of younger, low- or zero-parity clients.

Objective: This paper examines the association between birth intervals and infant and child mortality and nutritional status., Methods: Repeated analysis of retrospective survey data from the Demographic and Health Surveys (DHS) program from 17 developing countries collected between 1990 and 1997 were used to examine these relationships. The key independent variable is the length of the preceding birth interval measured as the number of months between the birth of the child under study (index child) and the immediately preceding birth to the mother, if any. Both bivariate and multivariate designs were employed. Several child and mother-specific variables were used in the multivariate analyses in order to control for potential bias from confounding factors. Adjusted odds ratios were calculated to estimate relative risk., Results: For neonatal mortality and infant mortality, the risk of dying decreases with increasing birth interval lengths up to 36 months, at which point the risk plateaus. For child mortality, the analysis indicates that the longer the birth interval, the lower the risk, even for intervals of 48 months or more. The relationship between chronic malnutrition and birth spacing is statistically significant in 6 of the 14 surveys with anthropometric data and between general malnutrition and birth spacing in 5 surveys. However, there is a clear pattern of increasing chronic and general undernutrition as the birth interval is shorter, as indicated by the averages of the adjusted odds ratios for all 14 countries., Conclusion: Considering both the increased risk of mortality and undernutrition for a birth earlier than 36 months and the great number of births that occur with such short intervals, the author recommends that mothers space births at least 36 months. However, the tendency for increased risk of neonatal mortality for births with intervals of 60 or more months leads the author to conclude that the optimal birth interval is between 36 and 59 months. This information can be used by health care providers to counsel women on the benefits of birth spacing.

The Sultanate of Oman, faced with the potential for a population explosion that would drain national educational and economic resources, has initiated a birth spacing program which is in its fifth year of implementation at all Ministry of Health facilities. The program was developed based on data from a survey of married Omani women of childbearing age and their spouses. Success has been attributed to the inclusion of Muslim religious leaders at all stages of planning and implementation to deflect people's concern that child spacing is forbidden, and to educational outreach to men.

No previously published study has provided evidence to support the frequently made assertion that closely spaced births increase the risk of maternal death. This study reviews the literature for evidence supporting an association between short birth intervals and maternal mortality and presents empirical evidence to address the question of whether short birth-to-conception intervals alter the risk of maternal death. In this nested case-controls study selected from a cohort of women under demographic surveillance in Matlab, Bangladesh, the length of the preceding birth-to-conception interval is found not to affect the risk of maternal mortality. These results do not support the claim that births that are too close increase the risk of maternal death.

The extent of men's roles in reproductive decision-making in Africa is a subject of contention. Despite the volume of work on the roles men play in fertility decisions, there have been few attempts to derive direct empirical estimates of the effect of men's preferences on reproductive behavior. I employ 1989 and 1993 Kenya Demographic and Health Surveys to examine the relative roles of the reproductive preferences of males and females on contraceptive use. Additive and interactive measures of preferences document a significant effect of men's preferences, which may eclipse women's preferences. The implications of these findings are discussed.

Qualitative and quantitative data are used to explore postpartum contraceptive use in two populations in Bangladesh. Findings from in-depth interviews with contraceptive users illustrate that women are primarily concerned with their own and their newborn child's health and well-being in the period following childbirth. In addition, women are aware of a diminished risk of pregnancy during the period of postpartum amenorrhea. These perceptions, plus a belief that modern methods of contraception are "strong" and potentially damaging to health, mean that the majority of women are reluctant to adopt family planning methods soon after birth, despite a desire to avoid closely spaced pregnancies. Supplementation of the child's diet is also shown to be an important factor determining the timing of postpartum contraceptive initiation. The findings suggest that current policies promoting contraception to women in the immediate postpartum period are inappropriate for many Bangladeshi women.

Intrauterine contraceptive devices (IUDs) have not suffered from the same negative influences in the developing world as in the first world. The method has too many basic advantages to be gainsaid including, most importantly, that it has the lowest lifetime cost of any effective method of contraception, and that user compliance is not an issue once the device is in place. However, the global community is not immune from trends that are seen in selected industrialized countries. Today, better methods of contraception are requested and the discomforts associated with earlier models of IUD, which were once acceptable, are less so today. Faced with the side-effects of oral contraception and the high cost in developing countries, many women who have completed their families undergo surgical sterilization as the only long-term method available to them, notwithstanding severe cultural and economic reservations about doing so. The development of the frameless device is a response to the growing need to develop high-performing, long-acting, reversible and acceptable contraceptives with a high continuation of use and to respond to the urgent need to reverse the legacy of neglect of immediate postabortal family planning.

This study examines the relationship between a woman's workload and the health of her pre-school children aged 24-59 months. The role of gender of alternate care givers when the woman is away from home is the specific focus of the research. Interviews were conducted with 106 women in rural Haiti, 44% of whom had malnourished children. Factors which significantly discriminated between normal and malnourished nutritional status were birth space between the index child and its next oldest sibling, number of children in the home, roof type (a proxy for socioeconomic status), and having a male substitute care giver. Further multivariate analysis produced a model which demonstrated that having a male care giver exacerbated the effect of birth space on nutrition status. Further research is necessary to determine characteristics of substitute care givers and their impact on nutritional status and child health in less developed countries. This is particularly important in light of the increased economic pressure on Third World rural women to work outside the home in order to meet the basic needs of their families.

This paper examines the association between infant mortality of the first born and subsequent children using data from rural Bangladesh collected during the period 1971-82. It shows that birth spacing and age of mother at the time of the second birth are important predictors of the survival status of the first child. The findings are discussed in terms of policy implications.

Data from 15 Demographic and Health Surveys are used to examine whether rural-urban migrants in developing countries experience higher child mortality after settling in towns and cities than do lifelong urban residents, and if so, what individual or household characteristics account for this. Findings indicate that children of female migrants from the countryside generally have much poorer survival chances than other urban children. This survival disadvantage is more pronounced in big cities than in smaller urban areas, among migrants who have lived in the city for many years than among recent migrants, and in urban Latin America than in urban North Africa and sub-Saharan Africa. Within big cities, higher child mortality among migrant women is clearly related to their concentration in low-quality housing, and in part to fertility patterns at early ages of children and mother's educational attainment at later ages. Excess child mortality among urban migrants may also result from factors associated with the migration process, that are outlined in this study but not included in the analysis. Evidence of moderately high levels of residential segregation of migrant women in big cities suggests that opportunities exist for urban health programs to direct interventions to this disadvantaged segment of city populations.

The question of how postpartum sexual abstinence responds to social change in West Africa is important because declines in the practice could increase fertility levels and worsen child and maternal health. This study uses data from the late 1970s in Cote d'Ivoire, Ghana, and Cameroon to examine effects of modernization and women's status on the length of abstinence. The results show that modernization and female status should be associated with declines in abstinence, which could lead to an increase in fertility and deterioration in maternal and child health.

Demographic, behavioural, environmental, economic and obstetric history data from the Jamaican Perinatal Morbidity and Mortality Survey were examined to identify characteristics of women who do not attend for antenatal care, or present late instead of early for care, using multiple logistic regression. Non-attenders were more likely to be teenagers, unmarried, in unions of very short duration, smokers and women who felt that friends and relatives were not supportive. Multigravid non-attenders often had short inter-pregnancy intervals and included women who had experienced a post neonatal death. They were often drawn from deprived environments (lack of sanitation, water supplies). Late attenders shared features common to non-attenders (teenagers, unmarried, multigravid). Many however were self employed and did not fit the depressed profile of the non-attender. Most multigravidae who attended late had had previously uneventful pregnancies, including this one. Early attenders had little in common with non-attenders or late attenders. They were older, many had a secondary or tertiary education, were married and were generally middle class women. The group however included high risk multigravidae who had previous pregnancy complications or bad outcomes. Programmes aimed at reaching non-attenders must focus on the wider social and economic needs of these women and must give them a sense of their own power to effect change in their lives. Reaching the late attender will be more difficult and may be unnecessary with the possible exception of the teenager. She needs to be treated in a more sympathetic and non-judgmental way as this is often a high risk pregnancy. More fundamental changes require improved educational and employment opportunities for women as the best consumer is an educated consumer.

Based on the 1989 Demographic and Health Survey of Bolivia, analysis of the joint effects of breastfeeding and contraceptive use on birth-spacing showed the IUD to be the most effective contraceptive method used to delay conception. Breastfeeding significantly lengthened the birth interval, but only following second and higher parity births. In addition, conditions of poverty appeared to further inhibit the return of fecundity and delay conception.

Using data from the 1988 Two-Per-Thousand Survey of Fertility and Birth Control, this paper examines the effects of gender, birth order, and other correlates of childhood mortality in China. Controlling for family-level factors, childhood mortality is found to be associated with the child's gender and birth order. Among firstborn children the difference between male and female childhood mortality is not statistically significant, but among others, female children between ages 1 and 5 experience higher mortality than male children. Childhood mortality is slightly higher for children who have older brothers only than for those who have older sisters only, and it is highest for those who have both older brothers and sisters. Other factors affecting childhood mortality in China include mortality of older siblings, birth interval, urban/rural residence, mother's level of education, and mother's occupation. All interactive effects between gender and family-level characteristics are found to be statistically insignificant.

Family planning can save lives of children and benefit the health of mothers, according to a study published recently by the UN Population Division. Entitled "The Health Rationale of Family Planning: Timing of Births and Child Survival," the study finds that survival of children can be improved through delaying child-bearing at least until the mother reaches age 18 and possibly age 20, and more especially through achieving birth intervals of at least two years. Those survival benefits are quite considerable, it states, and are likely to be complemented by wider health benefits for the child. For the health of the mother, the benefits lie in avoidance of the repeated risk of pregnancy and birth. The study encompasses over 280,000 births and nearly 35,000 deaths before age five in 25 developing countries. It recommends that family planning programs should highlight the importance of the appropriate timing of births and supply methods to achieve better spacing of births. Health programs should also encourage breast-feeding, not just to improve the survival and nutritional chances of the current child, but also to delay the next pregnancy and thus increase the survival chances of both the existing and the next child., (full text)

The 1988 Malawi Traditional and Modern Methods of Child Spacing Survey data are used to identify determinants of infant mortality in Malawi. The logistic binomial analysis shows that socioeconomic factors are significant even during the neonatal period while the length of the preceding birth interval is significant in the post-neonatal period only. There is a strong familial correlation of mortality risks during both the neonatal and post-neonatal periods but the effect of geographical area of residence is stronger in the post-neonatal period.

This report summarizes current knowledge about abortion in Vietnam, drawing upon government statistics, survey data, and fieldwork undertaken by the author in Vietnam throughout 1993 and part of 1994. The official total abortion rate in Vietnam in 1992 was about 2.5 per woman, the highest in Asia and worrisome for a country with a still-high total fertility rate of 3.7 children per woman. Vietnamese provinces exhibited substantial variation in both the rate of abortion and the type of procedures performed. Among the hypotheses explored to explain Vietnam's high rate of abortion are the borrowing of family planning strategies from other poor socialist states where abortion is common; current antinatal population policies that interact with a lack of contraceptive alternatives; and a rise in pregnancies among young and unmarried women in the wake of recent free-market reforms. Because family-size preferences are still declining, abortion rates may continue to increase unless the incidence of unwanted pregnancy can be reduced, a goal that Vietnamese population specialists are seeking to achieve.

The traditional preference for sons may be the main hindrance to India's current population policy of two children per family. In this study, the effects of various sociodemographic covariates, particularly sex preference, on the length of the third birth interval are examined for the scheduled caste population in Assam, India. Life table and hazards regression techniques are applied to retrospective sample data. The analysis shows that couples having two surviving sons are less likely to have a third child than those without a surviving son and those with only one surviving son. Age at first marriage, length of preceding birth intervals, age of mother, and household income have strong effects on the length of the third birth interval.

Postpartum sexual abstinence may be a major determinant of fertility and of maternal and child health in sub-Saharan Africa. This study examines the relationship between ethnicity and abstinence using data from the 1988 Ghana Demographic and Health Survey. There is considerable diversity in the length of abstinence although only for one ethnic group, the Mole-Dagbani and other Ghanaians, is abstinence, both actual and ideal, very long. Respondents in most ethnic groups believe their abstinence to be adequate. A key motivation for abstinence is the unwillingness to have sexual intercourse with nursing mothers. Education, urbanisation, changes in marriage patterns and religious traditions are major factors shaping the ethnic differentials in abstinence. In comparison to breast-feeding, abstinence appears to have relatively little impact on the length of the birth interval and for Ghana, has relatively few implications for fertility and child health.

Approximately half a million women in developing countries die each year as a result of complications during pregnancy. Sadly, illegal abortion is one of the five major causes of these deaths. International data suggest that maternal mortality is decreasing in regions where the use of family planning is increasing because of the consequent avoidance of unwanted pregnancies, although accurate data on maternal mortality are difficult to obtain in most developing countries. Use of family planning to delay first births and to increase interpregnancy intervals has the potential to decrease infant mortality by at least 20%. Data from developing countries show that some of this potential has already been realized during the past 20 years, but additional improvement is possible. In countries where maternal mortality is low, women may avoid using contraceptives because of the perceived dangers of the most effective methods. Recent analyses show that cardiovascular risks associated with oral contraceptives are low, and that the net effect of oral contraceptives on cancer of the ovary and endometrium is one of protection. While there remain unanswered questions regarding cervical and breast cancer, the net effect is small at worst.

The associations of social and behavioural factors on preterm birth in Singapore were studied using hospital maternity records of 20,723 consecutive singleton births between January 1986 and November 1991. The overall proportion of preterm births was 3.6%, the rates for the Chinese, Malay and Indian groups being 3.2%, 3.8% and 4.9% respectively. Teenage mothers were at a higher risk of preterm labour compared to women aged 20-29 years. The incidence of preterm labour decreased with increasing educational status. Preterm births were six times more likely in women who had no antenatal care. Women who had three or more previous births were at a higher risk, while those who had one or two previous births were at a lower risk compared to women who had none.

This study indicates that urban marital patterns in nine Nigerian cities influence fertility. Fertility is also influenced by age at marriage, region of residence, ethnicity and religion; education and employment lead to marriage delay and tend to conflict with childbearing by enhancing the status of women.

Intense, sustained nursing lengthens inter-birth intervals and is causally linked with low natural fertility. However, in traditional settings, the effects of such nursing on fertility are difficult to disentangle from those of nutrition. Results from a prospective, direct observational study of reproductive function in well-nourished Amele women who nurse intensively and persistently but who also have high fertility are here presented. Endocrine measures show that ovarian activity resumes by median 11.0 months postpartum. Median duration of postpartum amenorrhoea is 11.3 months, time to next conception is 19.0 months, and the inter-birth interval is 28.0 months. Average life time fertility is 6.8. High fertility in Amele women is due both to refractoriness of reproductive function to suckling stimuli, and to maintenance of equivalent age-specific fertility rates across the reproductive life span.

Community and hospital based studies were conducted to assess the major factors related to the practice of family planning during 1989 and 1990 in Central Sudan. The mothers of 1592 births in the community and 1357 births in the hospital were interviewed by trained study workers. Prevalence of contraceptive use prior to current pregnancy was 13.0% and knowledge of a family planning method was 43.0% among hospital women and 51.0% among community women. The major predictors of use of a family planning method were parity, socioeconomic status, knowledge of source of service and maternal age. The average completed family size was 7.7 children and with the exception of a lengthy breast feeding duration, the factors examined favored a high fertility. Women preferred and apparently practiced behaviors conducive to spacing rather than limiting the number of their children. The results between the hospital, the community, and the Sudan Demographic and Health Survey 1989/1990 were consistent suggesting a minimal effect of selection bias and increasing the validity of these findings. Accessible and available family planning services coupled with wider information on family planning through health personnel and the media are needed. In particular, special efforts should be made to reach women of low socioeconomic status.

The Cebu Longitudinal Health and Nutrition Survey is used to examine the roles of women's nutrition and infant feeding in determining time from birth to menses and time from menses to conception. The analysis sample includes 2,648 Filipino women followed for 24 months postpartum. Recently devised statistical estimation techniques to control for unobserved heterogeneity and endogeneity are employed in estimating a two-state hazard model. Low body mass index and lower dietary fat intake are associated with increased duration of postpartum amenorrhea. Contraceptive use, high dietary fat consumption, higher parity, and absence of spouse predict a longer waiting time to conception once menses have returned. Simulation of the hazard model is used to examine the effects of the key nutrition and lactation factors.

Gender preference, particularly son preference, is believed to sustain high fertility in many Asian countries, but previous research shows unclear effects. We examine and compare gender-preference effects on fertility in two otherwise comparable populations in Bangladesh that differ markedly in their access to and use of contraception. We expect, and find, stronger effects of gender preference in the population that has more access to contraception and higher levels of contraceptive use. Thus gender preference may emerge as a significant barrier to further national family planning efforts in Bangladesh. We find that if a woman has at least one daughter, the risk of a subsequent birth is related negatively to the number of sons. Women with no daughters also experience a higher risk of having a subsequent birth; this finding suggests that there is also some preference for daughters. Son preference is strong in both the early and later stages of family formation, but women also want to have at least one daughter after having several sons.

This paper studies the familial association of neonatal mortality in Matlab, Bangladesh and its relationship to birth-spacing effects on mortality. Findings show that familial association is strongest for siblings of adjacent birth orders. Moreover, birth-spacing effects on neonatal mortality are stronger when the preceding child has survived the neonatal period than when it has died. Transitional (Markov), random-effects, and marginal models for correlated data are introduced, and are contrasted in interpretation and technique. Familial association of neonatal mortality can be approximately well by a first-order Markov model using generalized estimating equations (GEE) to allow for higher-order correlation.

Selected determinants of overall infant mortality in Vietnam were examined using data from the 1988 Vietnam Demographic and Health Survey, and factors underlying neonatal and post-neonatal mortality were also compared. Effects of community development characteristics, including health care, were studied by logistic regression analysis in a subsample of rural children from the 1990 Vietnam Accessibility of Contraceptives Survey. Infant neonatal and post-neonatal mortality rates showed comparable distributions by birth order, maternal age, pregnancy intervals, mother's education and urban-rural residence. Rates were highest among first order births, births after an interval of less than 12 months, births to illiterate mothers and to those aged under 21 or over 35 years of age. Logistic regression analysis showed that the most significant predictor of infant mortality was residence in a province where overall infant mortality was over 40 per 1000 live births. In the rural subsample, availability of public transport was the most persistent community development predictor of infant mortality. Reasons for the low infant mortality rates in Vietnam compared to countries with similar levels of economic development are discussed.

Data from the 4172 women aged 15-49 interviewed in the 1988 Vietnamese Demographic and Health Survey were used to examine age at marriage, marriage to first birth intervals and age at first birth. Differences between urban and rural areas, northern and southern provinces and by education of the women were analysed. The majority of the women had their first birth before age 20, but women with secondary education had a significantly higher age at first birth than those with little or no education, and women from the north had a significantly higher age at first birth than women from the south. Rural women and those with little or no education married at significantly younger ages than urban women and those with secondary education; these education effects were confirmed in a rural subsample of women. Women from rural areas and from the north had significantly shorter marriage to first birth intervals than urban women and those from the south, but there were no significant effects related to education.

Using data from a Nepali population, this analysis argues that marriage style and postmarital living arrangements affect coital frequency to produce variations in the timing of first birth after marriage. Event history analysis of the first birth interval for 149 women suggests that women's autonomy in marriage decisions and marriage to cross-cousins accelerate the pace of entry into first birth. Extended-household residence with reduced natal kin contact, on the other hand, significantly lengthens the first birth interval. These findings are consistent with previous arguments in the literature while offering new evidence for the impact of extended-family residence on fertility.