Original Article Birth Interval and Adverse Childhood Nutritional Outcomes

Abstract

Introduction:
Short birth spacing is reported to have health
consequences for both mother and child. This study aims to
examine the effect of short birth interval on nutritional outcomes
of under-five children in Bangladesh.
Methods:
We used data from the latest five rounds of successive
Bangladesh Demographic and Health Surveys conducted during
2004 to 2017-18. Short birth interval is defined as birth spacing of
< 24 months between two subsequent live births. The outcomes of
interest are stunting and underweight. Both bivariate and
multivariate statistical analyses were employed. Results of the
multivariate analysis are shown by odds ratios (ORs) with 95%
confidence intervals (CIs). Data were analyzed by Stata 15/IC.
Results:
A total of 16,100 under-five children of second and
higher - order births were included for analysis. Of the children,
12% were born at a space of < 24 months, and 19% were born
with a space of 24 - 35 months. The proportion of children with
short birth interval was found decreasing over successive surveys.
Results of the logistic regression analysis show that compared to
the birth interval of 24 - 35 and 36 - 59 months, children born to
women with birth interval < 24 months were significantly (P <
0.001) at higher risk of being stunted and underweight.
Conclusions:
Short birth interval has significant impact on
childhood stunting and underweight. It remains a major factor
resulting in childhood malnutrition in Bangladesh. Research to
explore causal pathways and programs to lengthen space between
inter-pregnancy should be intensified.
Keywords: Birth interval; childhood nutrition; logistic regression;
stunting; underweight

Full text

Original Article
Birth Interval and Adverse Childhood Nutritional Outcomes; Kamal SMM et al.
J Nepal Paediatr Soc Vol 41 Issue 3 Sept-Dec 2021
327
Birth Interval and its Association With Adverse Childhood
Nutritional Outcomes Among Under-Five Children in
Bangladesh: A Longitudinal Study
SM Mostafa Kamal and Md Moniruzzaman
Department of Mathematics, Islamic University, Bangladesh
ABSTRACT
Introduction: Short birth spacing is reported to have health
consequences for both mother and child. This study aims to
examine the effect of short birth interval on nutritional outcomes
of under-five children in Bangladesh.
Methods: We used data from the latest five rounds of successive
Bangladesh Demographic and Health Surveys conducted during
2004 to 2017-18. Short birth interval is defined as birth spacing of
< 24 months between two subsequent live births. The outcomes of
interest are stunting and underweight. Both bivariate and
multivariate statistical analyses were employed. Results of the
multivariate analysis are shown by odds ratios (ORs) with 95%
confidence intervals (CIs). Data were analyzed by Stata 15/IC.
Results: A total of 16,100 under-five children of second and
higher - order births were included for analysis. Of the children,
12% were born at a space of < 24 months, and 19% were born
with a space of 24 - 35 months. The proportion of children with
short birth interval was found decreasing over successive surveys.
Results of the logistic regression analysis show that compared to
the birth interval of 24 - 35 and 36 - 59 months, children born to
women with birth interval < 24 months were significantly (P <
0.001) at higher risk of being stunted and underweight.
Conclusions: Short birth interval has significant impact on
childhood stunting and underweight. It remains a major factor
resulting in childhood malnutrition in Bangladesh. Research to
explore causal pathways and programs to lengthen space between
inter-pregnancy should be intensified.
Keywords: Birth interval; childhood nutrition; logistic regression;
stunting; underweight
Correspondence:
SM Mostafa Kamal
Department of Mathematics,
Islamic University,
Bangladesh
E-mail: kamaliubd@yahoo.com
DOI: 10.3126/jnps.v41i3.33562
Submitted on: 2020-09-12
Accepted on: 2021-06-27
Acknowledgements: None
Funding: Nil
Conflict of Interest: None declared
Permission from IRB: Yes
To cite this a rticle: Kamal SMM,
Moniruzzaman M. Birth Interval And Its
Association With Adverse Childhood
Nutritional Outcomes Among Under-Five
Children In Bangladesh: A Longitudinal
S tu dy. J N e p a l P ae d i a t r S o c .
2021;41(3):327-335.
This work is licensed under creative common attribution 3.0 license

Original Article
Birth Interval and Adverse Childhood Nutritional Outcomes; Kamal SMM et al.
INTRODUCTION
The birth interval is referred to the intermission
between two subsequent births of siblings. In recent
decades birth interval between two pregnancies has
gained significant research interest not only for
fertility reduction but also for the implications of
both maternal and child health outcomes in the low
and middle-income countries (LMICs). Both short
and very long interval between two successive live
births can place both mother and child at adverse
health outcomes for various reasons.1 Despite this,
short birth interval has attracted much attention
among researchers and policy makers as it is
associated with horrible health and pregnancy
outcomes,2 particularly for the mother and child.
Short birth interval is associated with a variety of
adverse health and pregnancy outcomes such as
increased risk of preterm birth, low birth weight,
small for gestational age births, and neonatal,
perinatal and infant mortality,3,4 autism
5, and
congenital anomalies.6 Short birth interval also
increases high blood pressure of mother and
contributes to morbidities like preeclampsia.7
Similarly, very long birth interval (A birth interval
of greater than five years) also increases pregnancy
complications like preeclampsia.7 Understanding
the increased adverse situation, the technical
consultants of the World Health Organisation
(WHO) recommended waiting at least 24 months
for conceiving again after a live birth, and a birth
interval of around 33 months.8 Thus, following the
literature and WHO observations, spacing of < 24
months between two successive live births has been
defined as short birth interval.
The practice of birth interval differs between and
within countries. In countries where fertility is
high, generally the birth interval is short. In
general, women with low or no utilization of
contraceptive methods are at higher risk of short
birth interval. The traditional belief, cultural norms
and usage of traditional family planning methods
may shorten the duration between two subsequent
pregnancies. A more recent review study on 2,802
documents re ported that maternal age and
ed uc a t i o n , s e x of th e pr e c e d i n g ch i l d ,
breastfeeding, socioeconomic status and parity are
important determinants of short and long birth
interval.9 An estimated one-fifth of the under-five
mortality in the LMICs can be averted by
increasing birth interval to more than two years.10
A study from the USA has shown that a short birth
interval compared to longer birth int erv al
significantly increases the risk of perinatal
mortality and low birth weight.11 Using 17th
Demographic and Health Survey data from LMICs,
a study demonstrated moderate influence on the
children’s nutritional status and weak association
with lower attendance at prenatal care.12 Very short
birth intervals of less than 21 months were found to
be significantly associated with increased stillbirth
rate and neonatal mortality in Bangladesh.13
Besides, short interval was found to be associated
with higher fertility in Brazil.14 In India, child’s
under-nutrition and adverse birth outcome (Low
birth weight) was found higher among those
children whose birth interval was less than two
years.15
The study of childhood nutritional status is of great
importance since undernourished children lose their
productive capability in their adulthood, which in
turn hampers the development of a country. A
landmark review of pieces of the literature suggests
that a short duration between inter-pregnancy is
positively associated with childhood nutritional
s t at u s, p ar t ic u la r ly w it h s t u nt i ng a nd
underweight.10-12,15,16 However, little is known
regarding the present status of the issue in
Bangladesh. Thus, this study aims to examine the
effect of birth interval on childhood nutritional
status, particularly stunting and underweight using
nationally representative data sets. Hopefully, the
findings will enrich the existing literature and help
the policy makers to adopt suitable strategies.
METHODS
In this study, we used data extracting from the
latest five rounds of Bangladesh Demographic and
Health Surveys (BDHSs) conducted during the
period 2004 to 2017-2018. The survey followed a
two-stage sampling procedure to gather information
from 78,175 married women aged 15 to 49 years
covering urban-rural areas and all administrative
regions. The survey gathered various socio-
demographic information including current age,
J Nepal Paediatr Soc Vol 41 Issue 3 Sept-Dec 2021
328

Original Article
Birth Interval and Adverse Childhood Nutritional Outcomes; Kamal SMM et al.
age at marriage, history of births, survival status of
children, fertility, maternal and child health care
status, nutritional status of mother and child etc.
The surveys recorded a total of 38,456 births born
to mothers in the last five years preceding the
survey. We excluded first order children from our
analysis. Moreover, twin births children and those
with missing information on anthropometric
measurements were also excluded.17 Besides, the
latest two surveys 2014 BDHS and 2017-18 BDHS
collected information of receiving maternal and
child health care only from those who were born in
the last three years preceding the surveys. Children
with missing information on maternal health care
services utilization, particularly antenatal care
(ANC) were also excluded from the analysis. Thus,
the final sample size of this study stood at 16,100
children aged 0 to 59 months.
The outcomes of interest are (i) stunting; and (ii)
underweight. Stunting and underweight of the
under-five children were measured from height-for-
age and weight-for-age z-scores. A child whose
height-for-age was greater than two standard
deviations (SDs) below the median of the WHO
reference population was classified as short or
stunted, and a child whose weight-for-age was
below two SDs from the median of the reference
population was considered as underweight. The
main explanatory variable in this study is the birth
interval between two successive births; and
particularly, the interval of the most recent two live
births. The birth interval was categorized as < 24
months, 24 - 35 months and ≥ 36 months. The other
covariates included for analysis are survey years
(2004, 2007, 2011, 2014 and 2017-18), wealth
index (poorest, poorer, middle, richer and richest),
place of residence (urban and rural), region
(Barisal, Chittagong, Dhaka, Khulna and Rajshahi),
women’s level of education (no education, primary,
secondary and higher), the current age of the child
(0 - 11, 12 - 23, 24 - 35, 36 - 48 and 49 - 59
months), birth order (second, third and fourth or
higher), wantedness of last pregnancy (wanted and
unintended), and receiving ANC at least once (no
and yes). The variable ‘wealth index’ was measured
from household amenities. The construction
procedure of the wealth index has been given
elsewhere.17 At present Bangladesh is divided into
eight administrative regions. Rajshahi division was
J Nepal Paediatr Soc Vol 41 Issue 3 Sept-Dec 2021
329
Figure 1. Trends of birth interval of women in Bangladesh

Original Article
Birth Interval and Adverse Childhood Nutritional Outcomes; Kamal SMM et al.
divided into Rajshahi and Rangpur divisions and
Dhaka division was divided into Dhaka and
Mym e nsingh di vision s in 2 0 10 a nd 2 015
respectively. We merged these and kept the
divisions as those were in 2004. The responses for
the wantedness of the last child were categorized as
by wanted then, wanted later and not wanted at all.
The latter two responses were merged and labeled
as ‘unintended’.
Simple cross-tabulation, bivariate and multivariate
statistical analyses were employed. Bivariate
analysis namely, chi-square tests, was applied to
examine the association between the outcomes of
J Nepal Paediatr Soc Vol 41 Issue 3 Sept-Dec 2021
330
Table 1. Percentage distribution of under-five children by their background characteristics and birth interval,
BDHS 2004-2018
Background
characteristics
Distribution of women
Birth interval (in month)
Chi-square
P-value
N
%
<24
24-35
36-59
Birth interval
<24
1879
11.7
---
---
---
24-35
3101
19.3
---
---
---
36
11120
69.1
---
---
---
Survey year
P<0.001
2004
3438
21.4
14.3
24.3
61.4
2007
2990
18.6
12.7
21.1
66.2
2011
4330
26.9
10.8
19.0
70.1
2014
2511
15.6
10.9
16.4
72.8
2017
2831
17.6
9.5
14.0
76.5
Wealth index
P<0.001
Poorest
4117
25.6
12.7
23.0
64.3
Poorer
3418
21.2
11.8
20.9
67.3
Middle
3067
19.0
11.5
19.0
69.4
Richer
2911
18.1
11.8
16.3
71.9
Richest
2587
16.1
9.8
14.8
75.3
Residence
P<0.001
Urban
3482
21.6
10.8
16.1
73.1
Rural
12618
78.4
11.9
20.1
68.0
Region
P<0.001
Barisal
962
6.0
10.9
15.0
74.1
Chittagong
3553
22.1
12.3
23.4
64.3
Dhaka
5186
32.2
11.2
19.5
69.3
Khulna
1475
9.2
9.6
11.4
79.0
Rajshahi
3593
22.3
9.9
15.7
74.4
Sylhet
1331
8.3
19.4
28.7
51.9
Women’s education
P<0.001
No education
4334
26.9
12.1
22.2
65.7
Primary
5248
32.6
11.4
19.8
68.8
Secondary
5608
34.8
11.5
17.1
71.4
Higher
911
5.7
12.2
15.6
72.2
Birth order
P<0.001
2nd
7152
44.4
11.8
18.2
69.9
3rd
4269
26.5
9.8
17.1
73.1
4th+
4679
29.1
13.1
22.8
64.1
Child age (in month)
P<0.01
0-11
4232
26.3
10.8
19.4
69.8
12-23
4245
26.4
12.8
18.8
68.4
24-35
3761
23.4
11.7
18.3
69.9
36-47
2090
13.0
11.1
19.5
69.4
48-59
1772
11.0
11.6
21.7
66.7
Wantedness of last child
P<0.001
Wanted
10422
64.7
8.3
16.6
75.1
Unintended
5678
35.3
17.9
24.1
58.0
Received ANC
P<0.001
No
7577
47.1
12.6
23.6
63.7
Yes
8523
52.9
10.8
15.4
73.8
Total
16,100
100.0
11.7
19.3
69.1

Original Article
Birth Interval and Adverse Childhood Nutritional Outcomes; Kamal SMM et al.
interest and multivariable logistic regression
(MLR) was applied to examine the effects of the
explanatory variables on stunting and underweight.
Before execution of the multivariate analysis,
multicollinearity was checked and found its non-
existence. Results of the MLR analyses are
presented by odds ratios (ORs) with 95%
confidence intervals (CIs). We set the level of
significance at α = 0.05. The statistical analyses
were executed by Stata 15/IC. In the study, we used
secondary data. The data sets were obtained from
MEASURE DHS upon request. Prior to the survey,
both oral and written consent was taken from the
respondents. The ethical approval was taken from
the Ethics Review Board of ICF International, USA
and the Ministry of Health and Family Welfare,
Bangladesh. Thus, it was not necessary to take
further approval from any other ethical approval
committee.
J Nepal Paediatr Soc Vol 41 Issue 3 Sept-Dec 2021
331
Table 2. Percentage distribution of stunted and underweight children by their background characteristics, BDHS
2004 - 2018
Background
characteristics
Stunted
Total
Underweight
Total
<24
24-35
≥36
<24
24-35
≥36
Survey year
P < 0.001
P < 0.001
P < 0.001
P < 0.001
P < 0.001
P < 0.001
2004
45.6
46.9
36.1
40.1
53.4
50.8
42.1
45.8
2007
49.2
49.7
40.2
43.4
47.0
46.0
39.6
41.9
2011
49.4
47.7
38.2
41.2
43.9
39.7
34.7
36.6
2014
39.3
36.7
32.0
33.6
40.2
36.9
29.4
31.8
2017
37.3
35.0
28.7
30.4
23.5
23.3
17.4
18.8
Wealth index
P < 0.001
P < 0.001
P < 0.001
P < 0.001
P < 0.001
P < 0.001
Poorest
53.2
52.2
44.6
47.5
53.1
50.6
43.3
46.2
Poorer
45.5
47.8
40.0
42.3
46.9
43.0
37.8
39.9
Middle
48.3
44.1
33.8
37.4
43.0
39.6
31.4
34.3
Richer
40.4
38.5
32.4
34.3
37.2
36.4
27.7
30.3
Richest
30.1
29.7
21.9
23.8
28.3
25.6
19.1
21.0
Residence
ns
ns
P < 0.001
ns
P < 0.001
P < 0.001
Urban
41.9
42.7
29.7
33.1
40.1
35.2
26.0
29.0
Rural
46.0
45.3
37.0
39.7
44.4
42.9
34.7
37.5
Region
P < 0.05
P < 0.05
P < 0.001
P < 0.001
P < 0.001
P < 0.001
Barisal
44.8
54.1
40.5
43.0
35.1
45.8
37.9
38.8
Chittagong
46.5
44.3
35.5
38.9
44.5
40.5
33.7
36.6
Dhaka
46.8
45.4
35.8
38.9
47.3
43.1
30.6
34.9
Khulna
36.4
35.3
30.0
31.2
35.7
36.0
28.8
30.3
Rajshahi
40.6
44.0
34.1
36.3
40.2
40.2
33.7
35.4
Sylhet
50.2
46.3
40.3
43.9
46.0
42.2
38.2
40.8
Women’s education
P < 0.001
P < 0.001
P < 0.001
P < 0.001
P < 0.001
P < 0.001
No
education
52.9
54.1
43.4
46.9
54.3
54.3
45.4
48.5
Primary
45.9
49.9
38.6
41.6
46.5
42.8
34.7
37.6
Secondary
41.7
33.3
29.7
31.7
36.6
30.8
24.7
27.1
Higher
24.6
22.8
16.3
18.3
18.2
17.9
15.2
16.0
Birth order
P < 0.001
P < 0.001
P < 0.001
P < 0.001
P < 0.001
P < 0.001
2nd
38.3
41.5
31.9
34.4
37.7
37.7
28.9
31.5
3rd
48.6
38.8
34.2
36.4
48.1
37.2
31.5
34.1
4th+
52.3
53.0
42.1
45.9
48.6
49.2
40.3
43.4
Child age (in month)
P < 0.001
P < 0.001
P < 0.001
P < 0.001
P < 0.001
P < 0.001
0-11
22.3
22.5
16.6
18.4
25.7
23.1
17.8
19.7
12-23
54.0
50.3
40.3
43.9
45.9
45.6
34.5
38.0
24-35
51.9
53.6
43.7
46.5
50.9
47.3
37.5
40.9
36-47
51.2
59.1
45.0
48.4
48.7
54.1
43.8
46.4
48-59
51.1
50.2
39.1
42.9
55.8
48.5
41.3
44.5
Wantedness of last child
P<0.01
ns
P < 0.01
ns
ns
P < 0.001
Wanted
48.2
44.8
34.5
37.4
44.7
42.1
31.5
34.3
Unintended
42.6
44.9
37.2
40.0
42.6
40.7
35.7
38.1
Received ANC
P<0.001
P < 0.001
P < 0.001
P < 0.001
P < 0.001
P < 0.001
No
51.3
50.9
42.4
45.5
51.6
48.1
41.5
44.4
Yes
38.7
36.5
29.9
31.8
35.3
32.5
25.9
28.0
Total
45.1
44.8
35.3
38.3
43.6
41.5
32.7
35.7

Original Article
Birth Interval and Adverse Childhood Nutritional Outcomes; Kamal SMM et al.
RESULTS
Table 1 represents the background characteristics of
under-five children. Of the children, slightly over
one in ten fell in the birth interval of less than 24
months and one fifth had a birth interval between
24 to 35 months. More children were from 2011
BDHS, one-fourth of the children were from
poorest households, slightly over one-fifth was
J Nepal Paediatr Soc Vol 41 Issue 3 Sept-Dec 2021
332
Table 3. Logistic regressions estimates of stunting and underweight among under-five children in Bangladesh,
BDHS 2004 - 2018
Background characteristics
Stunting
Underweight
OR
95% CI
OR
95% CI
Lower
Upper
Lower
Upper
Birth interval
<24
1.44***
1.27
1.57
1.42
1.27
1.58
24-35
1.35***
1.24
1.41
1.22***
1.12
1.33
36
Ref.
---
--
Ref.
---
---
Survey year
2004
Ref.
---
--
Ref.
---
---
2007
1.20***
1.08
1.34
0.88**
0.80
0.98
2011
1.15**
1.04
1.27
0.72***
0.65
0.80
2014
0.91
0.81
1.03
0.67***
0.60
0.76
2017
0.93
0.82
1.04
0.38***
0.33
0.43
Wealth index
Poorest
Ref.
---
--
Ref.
---
---
Poorer
0.88**
0.80
0.97
0.84***
0.77
0.93
Middle
0.74***
0.67
0.82
0.69***
0.62
0.77
Richer
0.66***
0.59
0.74
0.60***
0.53
0.67
Richest
0.44***
0.38
0.51
0.42***
0.36
0.48
Residence
Urban
Ref.
---
--
Ref.
---
---
Rural
0.91*
0.82
1.00
0.96
0.87
1.06
Region
Barisal
Ref.
---
--
Ref.
---
---
Chittagong
0.96
0.82
1.12
1.07
0.91
1.25
Dhaka
0.92
0.79
1.07
0.92
0.79
1.08
Khulna
0.70***
0.59
0.84
0.80**
0.67
0.96
Rajshahi
0.77***
0.66
0.90
0.88*
0.75
1.02
Sylhet
1.05
0.88
1.26
1.12
0.93
1.34
Women’s
education
No education
Ref.
---
--
Ref.
---
---
Primary
0.96
0.88
1.05
0.84***
0.76
0.91
Secondary
0.82***
0.73
0.90
0.71***
0.64
0.79
Higher
0.49***
0.40
0.60
0.47***
0.38
0.58
Birth order
2nd
Ref.
---
--
Ref.
---
---
3rd
0.96
0.88
1.04
0.94
0.86
1.03
4th+
1.15***
1.05
1.26
1.02
0.93
1.12
Child age (in
month)
0-11
Ref.
---
--
Ref.
---
---
12-23
3.65***
3.30
4.04
2.64***
2.39
2.93
24-35
4.01***
3.62
4.45
2.92***
2.63
3.24
36-47
3.87***
3.42
4.38
2.93***
2.59
3.31
48-59
2.99***
2.63
3.40
2.68***
2.36
3.05
Wantedness of
last child
Wanted
Ref.
---
--
Ref.
---
---
Unintended
0.97
0.90
1.04
1.02
0.94
1.10
Received ANC
No
Ref.
---
--
Ref.
---
---
Yes
0.83***
0.77
0.89
0.81***
0.75
0.87
Note: Level of significance *** P<0.001; *** P<0.01; and *** P<0.05.

Original Article
Birth Interval and Adverse Childhood Nutritional Outcomes; Kamal SMM et al.
urban residents, and more children were from
Dhaka division. Almost three-fifths of the mothers
of the children had some primary or no education.
Over 44% of the children were second-order births,
more than one-third were unintended and more than
half of the mothers received ANC services at least
for once.
Trends of birth interval of married women are
pictured in Figure I. As shown in the figure, short
birth interval of less than 24 months has declined
from 14% in 2004 to 10% in 2017-18. Besides, the
birth interval of 24-35 months has declined more
sharply from 24% in 2004 to 14% in 2017-18.
Altogether, birth interval of less than 36 months has
declined from 38% in 2004 to 24% in 2017-18.
Table 2 shows the differentials of stunting and
underweight by background characteristics of the
children in Bangladesh. Overall, the prevalence of
stunted and underweight children was 45% and
44% who were born with a birth interval of less
than 24 months. The corresponding figures for
those born with a birth interval of 24 to 35 months
were 45% and 42% respectively. The rate of
stunting and underweight was significantly higher
in the children with a short birth interval of < 24
months and 24 to 35 months compared to an
interval of ≥ 36 months. The other covariates found
statistically associated with stunting and
underweight were survey year, wealth index,
region, maternal education, birth order of the child,
child age and mothers’ receiving of ANC services
at least once.
Results of the MLR analysis for stunting and
underweight are presented in Table 3. The results
suggest that both stunting and underweight are
inversely associated with birth interval. For
instance, compared to a birth interval of 36 to 59
months, children born to mothers with birth interval
24 to 36 months (OR = 1.35, 95%CI: 1.24, 1.41)
and < 24 months (OR = 1.44, 95% CI: 1.27, 1.57)
were significantly at higher risk of being stunted.
On the other side, the likelihood of being
underweight was significantly higher in the
children born to mothers with birth interval 24 to
36 months (OR = 1.22, 95% CI: 1.12, 1.33) and <
24 months (OR = 1.42, 95% CI: 1.27, 1.58)
compared to those born at an interval of 36 to 59
months of the previous birth. Risk of underweight
status decreases consistently across survey years;
although the risk of being stunted increased in 2007
and 2011 significantly and then decreased in 2014
and 2017-18, the decrease was not found to be
statistically significant.
Household wealth index and women’s level of
education were statistically inversely associated
with stunting and underweight. Children from
Khulna and Rajshahi divisions compared to those
of Barisal division were more likely to be stunted
and underweight. Child age was found to have a
significant effect of being stunted and underweight;
however, it did not show any apparent pattern of
risk of increasing of stunting and underweight
status of the children. Fourth-order birth was more
likely to be stunted than second-order birth, but
birth order was not a significant predictor of being
underweight. The children whose mothers received
ANC services at least once were less likely to be
stunted (OR = 0.83, 95% CI: 0.77, 0.89) and
underweight (OR = 0.81, 95% CI: 0.75, 0.87)
compared to those whose mothers did not receive
any ANC services.
DISCUSSION
There is a general consensus that in most
developing countries, stunting and underweight
children are at higher risk of childhood mortality
and morbidity. The duration between inter-
pregnancy is identified as a vital cause of stunting
and underweight. In this study, we examined the
association of birth interval and childhood stunting
and underweight using nationally representative
longitudinal data sets extracting from the last five
BDHSs conducted during the period 2004 to
2017-18.
Our findings show that, on average, 10% of the
births had a birth interval of less than 24 months
and 14% had a birth interval of 24 to 35 months.
The corresponding figures in India were reported to
be 27% and 32% respectively.18,19 In Nepal, 23% of
the births were delivered within a short birth
interval of < 24 months.20 A study from Sub-
Saharan Africa reported that the proportion of
women having short birth intervals between two
subsequent births in Chad and the Democratic
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Original Article
Birth Interval and Adverse Childhood Nutritional Outcomes; Kamal SMM et al.
Re p u b l i c o f C on g o w a s 30 % an d 27 %
respectively.21 Moreover, this study shows that the
proportion of short birth spacing is being decreased
over time though the result was not found to be
statistically significant in the multivariate analysis.
Consistent with previous studies, our findings show
that short birth intervals are statistically associated
with a higher likelihood of childhood stunting and
underweight.2,17-22 A plausible reason may be that a
mother cannot recover biological maturity within a
concise period of her delivery, which in turn affects
the next pregnancy and resulting in low birth
weight of the child. In addition, food sharing and
rearing of two infants at same time and place would
pose the children at greater risk of being stunted
and underweight.
Our results that showed that children from poor
households and having no or low educated mothers
are more likely to be stunted and underweight. This
finding of ours is also in good agreement of earlier
studies conducted elsewhere.2,17-21 It is likely that
poor families cannot provide enough and nutritious
food to their children which results in an increased
risk of stunting and underweight. Besides, low
educated mother have no sufficient knowledge
regarding nutritious food which also place their
children at risk to be undernourished.
The other factors identified to have a significant
effect on stunting and underweight are region, birth
order, child’s age and mothers’ ANC seeking. The
children whose mothers received ANC services
than those whose mothers did not receive this
service were less likely to be stunted and
underweight. This finding is also concurrent to
those of earlier studies conducted elsewhere.14-17
ANC seeking is a vital factor for both mothers and
child health. It helps pregnant mothers in detecting
any complications earlier which can be solved by
the counselling and advice provided by the medical
personnel.
This study has some limitations and strengths that
urge to be discussed. This study is based on
retrospective information which is not free of recall
biases. We could not show causality due to the
cross-sectional nature of the data sets, urges the
need for prospective research. An important
limitation of the study is that the inclusion of
various survey data may have influenced to be
changed other variables over years. The main
strength of the study is the usage of nationally
representative data which are reliable and publicly
used around the globe. Moreover, the sophisticated
statistical analysis yielded quantitatively important
and reliable estimates.
CONCLUSIONS
Findings reveal that short birth interval
adversely affects the nutritional status of under-
five children in Bangladesh. Women should be
informed about the adverse health outcomes for
both mother and child that occur due to short
birth interval. Women should be motivated to
use a family planning method to lengthen the
space between subsequent pregnancies or to
limit childbearing who do not desire for more
children. Use of suitable family planning
methods may be the viable means of longer
spacing or limiting childbearing which in turn
may lessen undernourishment of under-five
children.
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