The Reduction in Total Fertility Rate Predicts One Fourth of the Gain in Child Height in the Last Decade: Evidence from 44 Low- and Middle-Income Countries

Abstract

Abstract Objectives Poor child growth is associated with losses in human capital and economic productivity. High fertility rates are an increasing concern in many low- and middle-income countries (LMICs). The link between population-level fertility and child height remains underexplored. Methods Data were from 88 cross-sectional Demographic and Health Surveys from 44 LMICs across three regions between 2000 and 2015. Sample sizes (number of children aged 0–59 months) were 287,032 for South Asia (SAS), 345,256 for sub-Saharan Africa (SSA), and 130,040 for South America (SAM). We explored the association between fertility and child height-for-age z-score (HAZ). Fertility was indexed using total fertility rate (TFR), the number of children born to a woman were she to survive through her childbearing years according to age-specific fertility rates. TFR was calculated at the village level using birth histories and age distributions of women aged 15–49 years. Fixed effects regression models were used to estimate the association between changes in village level TFR and changes in child HAZ. These models were adjusted for country fixed effects, survey-year fixed effects, clustering, and demographic and socioeconomic covariates for the child, mother, and household. Country-level regression decomposition analysis was used to estimate the contribution of the actual TFR reduction from World Bank data to the actual gain in child HAZ. Results On average, individual level HAZ was −1.46 (95% CI −1.47, −1.45) in SAS, −1.50 (95% CI −1.50, −1.49) in SSA and −1.19 (95% CI −1.20, −1.19) in SAM. Mean country level TFR was 2.69 (95% CI 2.36–3.01) in SAS, 5.21 (95% CI 4.96, 5.47) in SSA and 2.76 (95% CI 2.50, 3.02) in SAM. The adjusted fixed effects models showed that a 1-unit decrease in village level TFR was associated with a 0.20 (95% CI 0.18, 0.21) increase in child HAZ in SAS, 0.09 (95% CI 0.07, 0.10) in SSA and 0.15 (95% CI 0.14, 0.17) in SAM. Decomposition analysis showed that reductions in TFR explained 25.7% of the increase in mean HAZ across countries between 2000 and 2015. Conclusions These findings point to an underappreciated role of fertility in the global discourse on childhood stunting. Noncoercive policies, interventions and incentives leading to replacement level fertility have the potential to support rapid reductions in stunting required to achieve development goals. Funding Sources None.