Publications Summary

Document Type
Analytical Studies
Publication Topic(s)
Fertility and Fertility Preferences, Infant and Child Mortality
Angola, Benin, Burundi, Cameroon, Chad, Congo Democratic Republic, Gabon, Gambia, Ghana, Guinea, Kenya, Lesotho, Liberia, Madagascar, Malawi, Mali, Mauritania, Mozambique, Namibia, Niger, Nigeria, Rwanda, Senegal, Togo, Uganda, Zambia, Zimbabwe, Albania, Armenia, Egypt, Jordan, Kyrgyz Republic, Afghanistan, Bangladesh, Myanmar, Papua New Guinea, Guatemala, Haiti
Recommended Citation
Bietsch, Kristin and Rebecca Rosenberg. 2023. The Effect of Fertility Behavior on Child Survival: Evidence from the Demographic and Health Surveys, 2012–2022. DHS Analytical Studies No. 88. Rockville, MD, USA: ICF.
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Publication Date
September 2023
Publication ID


Reducing child mortality is a major public health concern. Its causes are widely debated. This is the fourth and largest study in a series of papers based on Demographic and Health Surveys that examine the relationship between birth spacing and infant and child mortality, which has been shown in numerous studies to be associated. The first DHS study included 17 surveys from 1990 to 1997, the second expanded to 52 surveys from 2000 to 2005, and the third included 45 surveys from 2006 to 2012. The current study includes 84 surveys from 56 countries, which were conducted from 2012 to 2022. There are no overlapping surveys between the third study and present study. All surveys in this report were publicly available as of July 2023. As in the third study, this report includes analysis of the association of maternal age and birth order on mortality. Over 3.7 million births in the 179 months before the surveys are included in the estimates of mortality for under 5 and child (age 1–5) mortality. Almost 1.3 million of these births took place in the 59 months before the surveys and are included in the analysis of early neonatal mortality (within 6 days of birth), neonatal mortality (age 0–1 month), post-neonatal mortality (age 1–11 months), and infant mortality (age 0–11 months). The study presents summary statistics for individual surveys and pooled results for bivariate and multivariate Cox hazard regressions for mortality. As found in previous studies, short birth intervals are associated with an increased risk of mortality for all age groups in this analysis. This is consistent for both the unadjusted and adjusted models. The shorter the birth interval, the greater the odds. First born children also experience greater odds of mortality than higher order children who were conceived three to four years after their next oldest sibling. With maternal age, the pattern is also similar to the most recent study, with children born to young mothers (under age 18) having an increased risk of mortality for all six mortality measures, and children born to women over age 35 having an increased risk for mortality before age 1, but similar risks to the reference group (women age 18–24) for child and under-5 mortality. The risk of mortality is highest for children with birth order 7 or greater. For birth orders 5 and 6, mortality risks are higher than the reference group (parity 1 and 2) after the neonatal period. Combining information on spacing, maternal age, and birth order, a child with two risk factors faces over a 50% increased risk of dying in the early neonatal period, neonatal period, the post- neonatal period, and infant period compared to a child with no risk factors. The children’s risk of dying under age 5 is 130% higher than a child with no risk. A child with all three risk factors has a risk of dying that is over 100% higher than a child with no risk in all mortality groups.


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