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立 政 治 大 學
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1 Introduction
Around 5.3 million children died in 2018 worldwide before reaching five years of age. Even more alarming is the fact that 75% of those children didn’t even live past their first year1. Infant mortality is a health tragedy that has greatly affected the world, much more so before the current reproductive health care technological developments widely diffused. Over the past decades, the world has constantly reduced the rates of death of this young and entirely dependent group, only in the past twenty-years the infant mortality death has been cut by half, falling from 56.3 to 28.9 deaths per 1,000 live births.
Nonetheless, the decrease of infant mortality has not been equal, as some regions are still falling behind in the reduction targets. Nearly 80% of the 4 million of the infant deaths of 2018 occurred in Sub-Saharan Africa or South Asia (49% and 30%, respectively).
On the contrary, in the latter half of the past century Latin America has had the best performance in reducing child mortality, with most countries reducing at least 20%
of their child mortality rates, while others –including Nicaragua– had cut off the mortality rates among children in half from 1980-2000 (Ahmad, Lopez & Inoue, 2000). Although, in Nicaragua the greater results of the reduction of the infant mortality rate were seen during the early 80s and from the mid-1990s throughout 2009, averaging a 5% yearly consistent decline. Nonetheless, in recent years the rate of infant mortality in the country has continued to decline but at a very slow rate reaching a decrease of 0.6% to 1% decline yearly (World Bank, 2020).
On the other hand, the good historical performance doesn’t hold as strongly when dissecting the comparison within the Latin American region. Nicaragua has the second largest infant mortality rate in Central America –and the 11th among Latin American countries– with a rate of 15.7 deaths of children belong one year old per 1,000 live births, i.e. 1.5% of Nicaraguan children will not live past their first year and 1.8% will pass away before turning five years old.
The target of the Sustainable Development Goals (SDGs) is to reduce by 2030 the child mortality to 25 per 1,000 live births, thus, the target has been met in Nicaragua since 2003. But the issue remains relevant because most of these deaths are preventable; under a free-public health care system and considering all the modern methods to prevent and treat diseases during early childhood the rate is still too high, even when compared to the Latin American average of 14 deaths per 1,000 live births. Among the main causes of
1 Statistics on number of infant deaths and infant mortality rates taken from the World Bank Data (2020).
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國立 政 治 大 學
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N a tio na
l C h engchi U ni ve rs it y
infant mortality in Nicaragua, the Ministry of Health points out the following reasons:
respiratory distress syndrome, sepsis, asphyxia, birth defects, pneumonia and severe diarrhea (Ministerio de Salud, 2008).
Nevertheless, all of these conditions and diseases have their own set of causes and triggers. Particularly, research has identified the largest causes in developing countries to be associated with malnutrition, as the lack of nutrients make children more vulnerable to infectious diseases, as well as quantity and frequency, namely mother’s birth parity and child spacing, since those dictate how resources are spread within the household (Blau, 1986). Indeed, the World Health Organization (WHO) has expressly suggested waiting at least 24 months after a live birth to attempt another pregnancy, that is, an interbirth interval of 33 months or roughly 3 years. The recommendation pursues the objective of reducing the risk of adverse maternal, perinatal and infant outcomes (World Health Organization, 2007).
Considering the above, the Nicaraguan government has recognized in official documents and large-scale health strategy planning that young mothers and short birth intervals have a deleterious effect in child health and development, increasing their risk of death (Ministerio de Salud, 2007). Within the same document, the country-level strategy for sexual and reproductive health highlights the main pathways towards improving mothers and children’s health: (1) Through sexual education, that leads to increase awareness of family planning and also increases teenage first sexual-act age; (2) through family planning and contraceptives, by actually meeting the unsatisfied demand and increasing the utilization rate; and through the improvement and expansion of health care services, such as increasing institutional births and the coverage of antenatal care.
Despite these guidelines, the issue lies on the lack of objective actions proposed nor taken. Sexual education remains a weak spot on the policy actions, as schools do not approach sexuality topics as properly and in-depth as it’s needed by the Nicaraguan youth.
In addition, there are many teenagers and young people that escape the policies as they are out of the educational system. There’s no evidence, despite being recognized as a potential influencing factor in infant, child and maternal mortality, that sexual education in Nicaragua addresses the importance of birth spacing as a tool to reduce the risk of exposing both mothers and children to health hazards.
On top of that, there’s also little evidence that supports the WHO claims of the deleterious effects of short or long birth intervals for the Nicaraguan case, nor there’s
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國立 政 治 大 學
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N a tio na
l C h engchi U ni ve rs it y
lot to be said about whether advocating to promote an optimal interval provides a viable infant and child mortality reduction route. The former lies on the fact that the promotion of a healthy-recommended birth interval is a not so well understood public health intervention, consequently also heavily underutilized (Norton, 2005). The importance of proper birth spacing is widely known, but for the Nicaraguan case, is based on evidence for other countries and regions and has not been used as a policy tool. Nicaragua, thus, has an unrealized potential of tackling infant and child mortality through polices directed to increase the spacing between births and improving mothers and children health through healthier reproductive practices.
1.1. Problem
On one hand, infant mortality remains high in Nicaragua, when compared to the Latin American statistics, and most of these deaths occur due to preventable diseases and health complications. On the other hand, a significantly large proportion of Nicaraguan mothers choose to have children very shortly spaced apart (less than 18 months). At the same time, it’s widely promoted by international organizations and backed on international research on the past century, that short child spacing does impact negatively the risk of death of a child and has deleterious health outcomes. Despite these broadly recognized propositions, there’s little evidence for the Nicaraguan experience regarding how impactful and damaging, if at all, can the short birth intervals be for child survival outcomes; and also, what possible mechanisms would those effects be attributed to.
1.2. Purpose
This study aims to provide evidence on the association between the length of birth spacing and infant mortality, and the mechanisms by which the interval produces deleterious effect in child survival for the Nicaraguan experience based on data from the Demographic and Health Surveys of 1998-2011. Particularly, this study’s purpose is to analyze how child spacing along with a set of other possible incidence factors can increase or decrease the risk of death that a child is exposed to; and which mechanisms will these results be associated with. Ultimately, the results provided by this research also aim to serve as baseline information for the policy makers and contribute to better shape public and private interventions towards addressing the health tragedy that is infant and child mortality. By providing evidence on this matter, policy makers can better shape their strategies towards reducing infant mortality and increasing the welfare of Nicaraguan families.
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國立 政 治 大 學