Decomposing Socio-Economic Inequalities in Nutritional Status among Siblings: Impact of Birth Order

Health status of children is the mirror of progress and development of a society and nation. In many developing countries, child malnutrition is a significant cause of death among children. Improving the health of children and women is not only a matter of human right imperative but is also a foundation for a better future. Impressive progress has been made in improving the survival rates and health of children, even in some of the poorest countries., since the 1990s. However, achieving Millennium Development Goal 4 (MDG 4), which postulates to reduce the global under-five mortality rates by two-thirds between 1990 and 2015, will require additional effort for most developing countries, including India. According to the USAID report on ‘basic support for institutionalizing child survival (BASICS, 1996)’, about 70 percent of all childhood mortality in developing countries is due to five major morbidities: diarrheal diseases, acute lower respiratory tract infection (ARI), malaria, measles, and malnutrition.

Malnutrition refers to a wide range of clinical condition which occurs when the individual’s nutrients intake is inadequate to support the body’s normal physiological activities including growth, tissues repair, prevention of and recovery from the diseases, regulatory of body function and reproduction (1). It arises from both the lack of availability of food and unequal distribution of food and complimentary food within families. The research on sibling composition is over a century old, Dumont in 1980, in his ‘social capillary theory” explained “dilution” of parental inputs meaning parental resources are finite, and as the number of children in the family increases, the resources accrued by any one child necessarily decline.

At the same time, scholarly attention directed to another parameter of family structure, sibling configuration- also referred to as sibling composition. Among the components of the sibling structure that may shape children’s status is birth order, differences in age between siblings (sibling density), number of children in the household (sibling size) and the relative number of boys and girls (sex composition) (2-3).The effects of the sibling structure speak to both intra-familial and interfamilial inequality.

Malnutrition among children is often by the synergistic effect of inadequate or improper food intake and repeated episodes of childhood diseases such as diarrhoea and improper care during illness (4).Mwagome and his colleague mentioned that globally, malnutrition stays a factor in 60% of 11 million deaths among children aged less than five years each year. Till date, several interventions to reduce the malnutrition have been advocated and enforced in different parts of the world. There is a lack of evaluation of such intervention to provide a corrective course of action.

India is a fastest growing country in terms of population and economy, with about 1.21 billion population (2011 census) and according to world bank report its population has been growing at a rate of 10-14 % annually, India’s GDP growth was 9.0 % from 2007 to 2008. Despite this recent achievement in economic growth, the fruit of development has failed to secure a better nutritional status of children in India (5-6). Exhibiting sluggish declining trend over the past decade and a half, prevalence, however, become unimpressive with the average levels marked by wide inequality in childhood malnutrition across the states and various socio-economic groups (6,7).

In developing countries like India, various form of malnutrition affects a large segment of the child population (8). According to NFHS 3 2005-06, in India, around 48 percent of children are stunted below the age of five 19.8 percent are wasted, and 42.5 percent are underweight (9).Many of these children are severely malnourished. The prevalence of malnutrition varies across the states, with Uttar Pradesh recording the highest stunting (56.8 percent) children followed by Bihar (55.6 percent) and Kerala among the lowest (24.5 percent) followed by Goa (25.6 percent) (9). Growing pieces of evidence suggest(6) that in India, the gap in the prevalence of underweight children among the rich and poor households is increasing over the years with wide regional differentials. Data shows that undernutrition remains a leading problem in most of India, but it is more pronounced in the northern state of India such as Uttar Pradesh, Bihar, Rajasthan, and Madhya Pradesh. In these states, more than half of the children are underweight and stunted. Nearly 50% of the children in Orissa, Maharashtra and West Bengal are underweight, while 50% of the children in Assam and Haryana are stunted. States with the lowest percentage of underweight or stunted children are Goa, Kerala and all the small northern-eastern states except Tripura and Meghalaya (10-12). The reduction of child malnutrition is one of the most desirable components of the development, as it is strongly associated with increased child mortality and morbidity. There is now enough evidence that inadequate nutrition that childhood hinders long term physical development, reduces the development of cognitive skills, and, as a consequence, in the later years, it negatively affects the schooling and several other outcomes such as lack of productivity, the likelihood of development of chronic diseases and mortality (13-15).

At a household level, the common causes of undernutrition include inadequate access to food, poor sanitation, insufficient health care, and childcare (16). The economic status of a household is an important indicator of access to adequate food supplies, use of health services, which are prime determinants of child and maternal nutritional status(17). A study conducted in local parts of Ethiopia showed that the higher the level of the economic status of the household, the lower the level of child stunting (18).

Education is an important resource that enables women to provide proper care for their children, which act as a determinant of children’s growth and development (19). Maternal education influences the duration and quality of breastfeeding (20) and mother’s education has a direct effect on stunting. (21)Generally, children whose mothers had secondary or higher education are better nourished than children whose mothers had less education (22).The level of mother’s education is vital, as educated mothers usually follow instructions about feeding and caring for children and also use curative and preventative health services more often than women with little or no education. Sometimes, educated mothers also have an economic advantage over less educated mothers making their children better nourished and less susceptible to infection according to a study on the significance of mother’s occupation in Malawi (23).

A report on child nutrition in India shows that people belonging to both Hindus or Muslims religion have almost the same prevalence of stunting, also a comparatively higher prevalence of stunting than children belonging to other religion. Similarly, scheduled castes or scheduled tribe children have a significantly higher incidence of stunting than others. The prevalence of stunting by geographic region shows that both the unadjusted and adjusted prevalence of stunting is highest in the north-central region and lowest in the south (21), confirming pieces of evidence from other studies showing age and sex of a child and socio-economic characteristics as an important determinant of under-nutrition (24,17).

In India, culturally bound psychological notion plays a contagious role even in determining the preferences given to specific siblings for distribution of food in the family, in some places son preference is also responsible for the development of such biases, which further plays a significant role in determining the healthy growth of the children. Often these gender biases are profound among infant and children leading to the prevalence of stunting, wasting, and underweight (25).Birth order of the child is one of the demographic variables explaining the neglects in nutrition and health care access. Results based on birth order shows that more siblings in a household can increase competition for household’s limited resources, can have a negative impact on children’s nutritional status in these households(26). The higher birth order children are considerably more likely to be stunted than are children of lower birth orders (21). Studies revealed that children having same-sex siblings have a higher probability of dying, and this is worse for girls than boys in India (25,27). Study based on NFHS shows that the boys are less likely than girls to be stunted when all older living siblings are girls and more likely than girls to be stunted when all older siblings are boys. This pattern is also observed at birth order 4+ in NFHS-1, but not in NFHS-2 (28).

The literature indicates that previous concerns were mostly on the impact of ethnicity, regional variation and socio-economic status on the nutritional status and heath outcome of the child and in India numerous studies have been conducted on the effect of son preference over daughter as a reason for biases toward a male child having better nutritional status and child health care utilization for years(29,30). However, research on the nutritional status by number and sex composition of a sibling in the Indian context is scarce and. Thus, firstly, the present study will examine the association of sibling composition and gender differentials on under-five malnutrition in high fertility and low fertility states in India. Secondly, the paper assesses the in inequality in nutritional status among siblings in selected high and low fertility states in India.

Data Source

This study used data from national family health (NFHS-4) survey conducted in 2015-16 in India.It is a large-scale, multi-round survey conducted in a representative sample of households throughout the country. The survey is cross-sectional in design and follows a multistage stratified random sampling designby rural and urban areas. The sample sizes for the present study were 99,935 children for high fertility states and 20,007 children for low fertility states. women in the 2015–16 survey (ICF and IIPS, 2017) (31).

High Fertility States: Uttar Pradesh, Bihar, Madhya Pradesh, Rajasthan and Uttarakhand.

Low Fertility States: Andhra Pradesh, Kerala, Karnataka, Tamil Nadu and Kerala.

The level of fertility of the states have been determined by the replacement level fertility.

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Place Order

Outcome variable

WHO Child Growth Standard, Classification of SD

• Stunting: According to WHO “the children whose height for age is below minus two SD from the median height for age of the standard reference population are considered as stunted.”
• Wasting: According to the WHO “the children whose weight for height is below minus two SD from the median weight for height of standard reference population are considered as wasted.”
• Underweight: According to the WHO “the children whose weight for age is below minus two SD from the median weight for age of standard reference population are considered as underweight.”

Exploratory variables

The predictor variables are: Child’s age in months (Male composition

1. Male with 1 brother and 1 sister
2. Male with 2 brothers and 2 sisters
3. Male with than 2 brothers and 2 sisters

Female composition

1. Female with 1 brother and 1 sister
2. Female with 2 brothers and 2 sisters
3. Female with more than 2 brothers and 2 sisters

Methodology

To achieve the objectives of the study bivariate and multivariate analysis is carried out.Bivariate analysis (Cross tabulation) has been carried out to compare the nutritional status among sibling in high and low fertility states of India. To create the siblingcomposition, information on the number of boys and girls at home and elsewhere the total number of children was calculated, and the several categories were created. To understand the gender differential in nutritional status among sibling in high and low fertility states, Bivariate analysis has been carried out. For decomposition of concentration index, we have used (32), method which demonstrate that the health concentration index can be decomposed into the contributions of individual factors to income-related health inequality, in which each contribution is the product of the sensitivity of heath with respect to that factor and the degree of income-related inequality in that factor. For any linear regression model, linking the health variable of interest, y, to a set of k health determinants, Xki:

y_i = α + ∑▒〖β_k x ̅_k 〗 + ε_i ……………………. (1)

Where ε is an error term, given the relationship between y_i and X_ki in equation, the concentration index for y (C) can be written as:

C=∑▒〖((β_k x ̅_k)/µ〗 )C_(k )+GCε/µ/ µ ……………………..(2)

whereµisthemeanofy,x ̅_kisthemeanofxk,Ckistheconcentrationindexforxk(definedanalogouslytoC),andGCεisthegeneralizedconcentrationindexforthe errorterm(ε).

Equation (2) shows that C is made up of two components: deterministic or ‘explained’ component, equal to a weighted sum of the CIs of the regressors, where the weights are simply the elasticities an elasticity is a unit free measure of (partial association), i.e. the percentage change in the dependent variable associated with the percentage change in the explanatory variables. The second is a residual or ‘unexplained’ component. This reflects the inequality in health that cannot be explained by systematic variation in the xk across socioeconomic groups (32-33).

Ethics:

The authors assert that all procedures contributing to this work comply with the ethical standards of the National Family Health Survey. NFHS-4 has been conducted under the scientific and administrative supervision of the International Institute for Population Sciences (IIPS), Mumbai, India which is associated with the Ministry of Health and Family Welfare (MoHFW), Government of India (GOI). The institute conducted an independent ethical review of NFHS protocol.

This study performs an empirical analysis to understand the scenario of child malnutrition in India and highlight its distributional features and major determinants. The study indicates the fact that an alarming proportion of undernutrition exists among Indian children and whose concentration was highest among boys and girls with 4 siblings and poor at the same time. Although India had impressive economic growth in the past years, the findings of the study suggest that India is still performing very poor in the field of maternal and child health. From a policy perspective, the measure should be promoted to reduce inequality between poor and non-poor in low fertility states so that more and more concentration of inequalities among poor could be avoided whereas greater attentionneeds to be laid towards improving the child health conditions in high fertility states. The study shows that substantially high level of undernourishment is found among the poor children who are an outcome of their poor economic condition whereas the presence of under-nutrition among comparatively better among non-poor families is perhaps due to influence of social factors like lack of awareness and improper feeding practice evident in previous studies (World Bank 2004). Though several kinds of literature prove that poverty is a basic influencing factor causing persistence of under-nutrition in India; the rising level of inequality is slowing down the pace of progress which is also reflected in the slow reduction in under-nutrition level. The inequality in child’s nutritional achievement by economic strata, the social group, are visible and need to be cured. Such removal will help to reach Millennium Development Goals further.

Further, this paper identifies the mediating characteristics that have abearing on the nutritional status of the child. Simple bivariate and multivariate analysis were done to find out the difference in nutritional status (stunting, wasting or underweight) of children according to their sibling composition in high fertility and low fertility states. The use of this method allows quantifying the differences in the effects of determinants and their interaction. The results of the paper indicate that children in a poor household and having 4 siblings at the same time are consistently at a disadvantaged position in both high fertility states and low fertility states across nearly all determinants affecting childhood nutritional status. Here the distribution of individual characteristics like maternal education, religion, caste, and economic status are the important influencing factors in child nutrition.

Children whose mothers had completed secondary and higher education were at a higher probability of having less child malnutrition compared with children whose mothers had no formal education. These findings are consistent with previous (34). This is probably because education provides the knowledge and awareness of rules of hygiene, feeding and weaning practices and the level and quality of nutrient intake according to the age of the child are clearly affected by maternal education and household economic status. Also, age of the child and birth order were observed to be important factors behind the poor nutritional status of the children, but if a mother is educated, can certainly be more efficient in childcare with limited resources in a household. There are also some ethnic and religious differences in the level of malnutrition, for instance, children from schedules tribes and castes experience high malnutrition. The effects of religion are more consistent, Muslim experience higher morbidity and malnutrition than Hindu as also reported by others, e.g.(35).

The study highlighted that children living in low fertility states are at a lower probability of having under 5 malnutrition rather than children living in high fertility states. The state or region’s wealth also plays a major role in organization of health services, policies, and food availability. Previous studies have suggested that regional economic development is one of the potential sources of regional variation in malnutrition (stunting, wasting, and underweight) (23). Another study in India found that there is a significant variation in education between the regions of India after controlling for individual demographic factors, for instance in the high fertility states (northern states) in India like Uttar Pradesh, Bihar, etc. women have a very low level of education compared to low fertility (southern states) of India. However, even the socioeconomic and education status of the household in these states are related with the place where these women live, the results of this study demonstrate that regional variation also plays an important role influencing the nutritional outcomes of the children in India (36).

Coming to the sibling composition and its association with nutritional status among children. Overall the findings suggest that the children with more surviving sibling in the household are more likely to be stunted, wasted and underweight as compared to children with less no. of sibling as mentioned in previous studies for instance, boys and girls with no older surviving siblings and those with only surviving siblings of the opposite sex were comparatively better than the others (25). Further, to find the main contributors to inequality in nutritional status decomposition analysis was carried out and the findings from the analysis reveal that child with 2+brother and 2+ sister and 1 sibling composition, birth order 3 and above, caste, religion are the main contributors in inequality for stunting, wasting and underweight in selected states in India. This study found an enormous unequal distribution of wealth, which was disproportionally concentrated particularly among women who live in a rural area. Also, women with secondary and higher education, 2+brother and 2+ sister and another sibling composition, birth order 2 and 3& above, belong to SCs and STs caste and both Hindu and Muslim religion have a high marginal effect on the malnutrition with high wealth inequalities in selected states in India.

The study presents a piece of strong evidence that economic condition of the family and the more no. of children in a household can transcend the demographic and social factors and cause malnutrition and other severe morbidities among children under five leading to high under-five mortalities. It is evident that higher order births among mothers and sibling composition above 4 and 2 often lead to neglect and unequal distribution of food and health care.