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1
Introduction
Barney Cohen and Mark R. Montgomery
BACKGROUND
The twentieth century has witnessed a remarkable expansion in the average
length of human life. Significant differentials in mortality remain, to be sure, and
these testify to the continued presence of political and socioeconomic barriers to
effective health care. The differentials should not, however, obscure the larger
achievement. In developed countries, the oldest generation living today was born
in an era in which nearly one child in five failed to survive to his or her fifth
birthday. In developing countries, for the most part, mortality risks are now far
lower than they were at the turn of the century in the wealthier societies of the
West.
This profound change in the human condition has had far-reaching implica-
tions, unsettling long-established habits of thought and behavior. As early as
mid-century, Notestein (1945, 1953) recognized and began to emphasize one
particular implication: the effects of mortality decline on the motivation for high
fertility. The initial formulations of demographic transition theory gave promi-
nence to this theme and it continues to serve as a unifying feature in models of
fertility and related demographic behavior (Mason, 1997~. Even when first ar-
ticulated, the mechanisms by which mortality reduction might bring about fertil-
ity decline were understood to be complex, involving both individual- and soci-
etal-level responses. Subsequent demographic research has done much to clarify
the individual-level relationships, and in so doing has added new considerations.
In 1975, a scientific meeting organized by the Committee for International
Coordination of National Research in Demography synthesized and codified what
had been learned. The resulting volume, The Effects of Infant and Child Mortal
1
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2
INTRODUCTION
ity on Fertility (Preston, 1978a), stands as a landmark in demographic research.
It enumerated four mechanisms by which child mortality might affect fertility.
First, parental expectations of child loss might be expressed in insurance or
"hoarding" behavior, causing fertility to be higher than if survival were assured.
In the event of an infant or child death, two additional mechanisms could come
into play: lactation interruption effects and behavioral replacement strategies.
Fourth, the Preston volume made a place for societal-level effects, those having to
do with institutional forces that had long served to maintain high fertility in the
face of high mortality, and which would therefore continue to shape the fertility
response to mortality decline.
Having summarized the key mechanisms, the 1978 volume went on to refine
the methodological tools with which the strength of the individual-level effects
might be measured. The volume also presented an array of applications to both
aggregate- and individual-level data, which provided evidence on the likely mag-
nitude of the fertility response. These theoretical and methodological develop-
ments were set out in compelling, lucid, and vivid terms. Interestingly, the net
effect was to dissipate much of the momentum for further research.
In retrospect, the ensuing lull in research appears all the more curious.
Preston's introduction to the 1978 volume pointed toward new intellectual terri-
tory into which demographers had not yet ventured (Preston, 1978b). He argued
for a deeper consideration of the societal-level mechanisms, including the place
of nuptiality, and emphasized the role of mortality perceptions. Yet neither line
of research was pursued. The new tools of hazard-rate modeling were just then
coming onto the demographic scene, accompanied by a dramatic expansion of
individual-level data in the form of World Fertility Surveys and the later Demo-
graphic and Health Surveys. Armed with these tools and new resources, re-
searchers were soon much better equipped to understand the multiple determi-
nants of birth interval dynamics and to explore the effects of high fertility and
close birth spacing on mortality. Yet relatively little attention was given to the
possibility that earlier estimates of the effects of mortality on fertility might be
contaminated by reverse causation. Continued advances in the availability of
historical demographic data also invited a reexamination of the Western experi-
ence, but on this front, too, progress was slow (although see Chesnais, 1992~.
New theoretical and empirical research in economics began to underscore the
importance of health to economic productivity and growth and put increasing
emphasis on the trade-off between such investments in human capital and the
level of fertility (Becker et al., 1990; Mincer, 1996~. Apart from the review by
Lloyd and Ivanov (1988), however, no systematic effort was mounted to draw
together such important but rather disparate lines of research.
In the early l990s, a spirited debate broke out in which the long-term ben-
efits produced by child health programs were brought into question. In a series of
provocative articles, King (1990, 1991, 1992) argued that in certain cases, pro
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BARNEY COHEN AND MARK R. MONTGOMERY
3
grams aimed at reducing infant and child mortality might do no more than exac-
erbate the problems of sustainable development. For the poorest countries in the
world, King said, the rapid increase in population generated as a direct result of
saving lives had the potential to undermine biological support systems to the
point that death rates might begin to climb. King termed this phenomenon a
"demographic trap" (see King, 1990, 1991; Hammarskjold et al., 1992~.
Other writers sharply disagreed, arguing in the first place that health pro-
grams can and should be justified on their own terms (Taylor, 1991; UNICEF,
1991~. Moreover, it was said, policies and programs aimed directly at high
fertility will tend to be more effective when parents can be confident that their
children will survive (Freedman, 1963; Taylor et al., 1976~. In addition, the
potential feedback benefits of fertility decline were cited, these having to do with
the role of lower and better-spaced fertility in reducing the risks of maternal,
infant, and child mortality. In the view of King's critics, health and family
planning programs have the potential to set off a series of responses that could
culminate in a more-than-compensating fertility decline over the long term. The
possibility of such responses in fertility can be glimpsed in recent cross-country
analyses of mortality-fertility relations in low-income countries (Schultz,
1994a,b)i and in new analyses of the historical record (Galloway et al., in this
volume).
To be sure, if attention were to be confined to the lactation interruption and
behavioral replacement effects, such overcompensating fertility responses could
be dismissed as implausible on empirical grounds. Citing numerous early studies
that found the responsiveness of individual fertility to the loss of a child to be
much less than one-for-one, Preston (1978b) concluded that, on average, an
additional child death in a family would lead to something less than an additional
birth. If the lactation interruption and replacement effects were indeed the only
mechanisms at work, then reductions in infant and child mortality would, by
themselves, tend to increase the rate of population growth. The possibility of
more-than-compensating effects thus rests on the insurance motivation and on a
longer-term series of feedbacks whose causal basis is yet to be fully understood.
iSchultz used data from 62 low-income countries in 1972, 1982, and 1988 to investigate the
relationship between fertility and mortality at the macro level. In his analysis (Schultz, 1994b:27):
Declines in the level of child mortality in developing countries are not associated with
increases in population growth, because coordinated fertility decline fully offset this de-
mographic effect of improvements in child nutrition and survival. In this time period,
improvements in child health are associated with slower population growth.
Schultz found that female educational attainment was the most important determinant associated
with both lower child mortality and lower fertility.
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4
INTRODUCTION
THE NEED FOR REASSESSMENT
The recent policy debate, and more generally the lack of systematic research
over the past 20 years, would suggest that a thorough reassessment of the theory
and evidence is in order. This volume is based on a set of papers presented at a
scientific meeting organized in November 1995 by the U.S. National Academy of
Sciences' Committee on Population and convened in Washington, D.C. It at-
tempts to contribute to the debate by advancing the demographic literature on
three fronts: theoretical, methodological, and empirical.
Given the current state of the research and policy debate, several tasks faced
the authors of this volume. The first imperative was simply to document, more
precisely than had previously been possible, the various pathways that have been
taken by mortality and fertility in the developing countries and in selected histori-
cal settings. When the full empirical record is assembled, it is seen to encompass
a remarkable diversity of experience. Many countries have adhered to the simple
scheme of demographic transition in which mortality declines first and fertility
decline then follows with a lag. Even here, however, the lags in response are
highly variable and are themselves worthy of consideration. Some countries
(e.g., Costa Rica, see Rosero-Bixby, in this volume) experienced decades of
profound mortality decline without any apparent fertility response. In a few
others, fertility decline seems to have preceded mortality decline.
The very diversity of developing country mortality and fertility declines
suggests that there can be nothing automatic or self-sustaining about the effects
of mortality decline on fertility. This diversity should also put to rest the notion
that mortality decline can be linked to fertility decline by way of simple neces-
sary or sufficient conditions. It seems that a particular configuration of social,
political, and economic forces may be required for any given country to embark
on transition, but the outlines of that configuration may be difficult to discern in
advance.
A second task facing the authors was to assess, with new data and tech-
niques, the robustness of the lactation interruption and replacement effects that
Preston had described earlier. Given the debate within the policy community, it
was important to determine whether, taken together, these effects could not rea-
sonably be expected to induce more-than-compensating fertility responses. In
this volume, a considerable amount of statistical and methodological ingenuity is
expended in securing precise estimates of the lactation and replacement effects.
The conclusion reached by this new research is that the earlier findings are indeed
robust.
This brings to the forefront the remaining task that faced the authors: to
better understand the role played by insurance (or hoarding) effects. If the lacta-
tion and replacement effects are less than compensating, the net reproduction rate
will fall in response to mortality decline only if the insurance effects are power-
ful. Such insurance effects are very difficult to detect with aggregate data, or
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BARNEY COHEN AND MARK R. MONTGOMERY
s
indeed, with any demographic data that are routinely collected. Something of
their influence is presumably expressed in the coefficients of community mortal-
ity measures employed in individual fertility regressions, but even this is too
crude a measuring device. The essence of the insurance effect resides in the
combination of individual experience and social structure that shapes individual
perceptions of mortality and forms the basis of their expectations. It is closely
linked to the perceived potency of human agency as against fatalistic views of the
world, and likewise to the transition from family building by fate to family
building by design that Lloyd and Ivanov (1988) have emphasized. Remarkably
little demographic research has addressed these fundamental concerns.
In the remainder of this introductory chapter, we review the research devel-
opments since the landmark Preston (1978a) volume. We offer our views as to
why the relationship linking mortality decline to fertility is likely to resist simpli-
fication and easy generalization. We then document the astonishing diversity of
mortality and fertility transitions that have taken place in developing countries
over the past 40 years. The penultimate section of this chapter previews the
contribution of the remaining chapters in the volume. The final section offers
brief conclusions and draws out some implications for policy.
THE RECENT RESEARCH RECORD
Since the 1978 Preston volume, research on the effects of mortality on fertil-
ity has proceeded in three directions. First, some researchers have continued to
search for statistically significant thresholds of life expectancy or socioeconomic
development that, when attained, provide motivation for couples to limit their
fertility (see, for example, Cutright, 1983; Cutright and Hargens, 1984; Bulatao,
1985~.2 Such studies have generally failed to identify meaningful thresholds for
fertility decline, although measures of social development often appear to be
more closely associated to declines in fertility than are measures of economic
development (Cleland, 1993~.
Second, the emergence of detailed m~cro-level data from developing coun-
tries has supported a new generation of studies of both the lactation interruption
and replacement effects (A.I. Chowdhury et al., 1992; A.K.M.A. Chowdhury et
al., 1976; Balakrishnan, 1978; Park et al., 1979; de Guzman, 1984; Mauskopf and
2Cutright and Hargens (1984) analyzed a pooled regression of crude birth rates from 20 Latin
American countries for four points in time. They found statistically significant threshold levels of
literacy and life expectancy that are independent of lagged measures of literacy and life expectancy,
measures of economic and family planning program development, and period controls. Bulatao
(1985) analyzed data from 124 developing countries and concluded that no fertility transition has
been observed in any developing country until life expectancy has reached 53 years. In a similar
analysis, Ross and Frankenberg (1993) concluded that fertility is unlikely to decline until life expect-
ancy rises to 50-60 years.
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6
INTRODUCTION
Wallace, 1984; Mensch, 1985; Santow and Bracher, 1984; Nur, 1985; Rao and
Beaujot, 1986; Johnson and Sufian, 1992~.3 These micro-level studies have
confirmed that women who experience the death of one or more of their children
tend to have higher subsequent fertility than women whose children survived.
Birth intervals tend to be considerably shorter following the death of a child, with
much of this due to the interruption of lactation and the removal of its contracep-
tive protection. When adjustments are made for duration of exposure and other
demographic and socioeconomic factors, the residual replacement effect esti-
mates have tended to be rather small. In marked contrast to studies of lactation
and replacement effects, relatively few micro-level analyses have attempted to
link fertility change to community-level changes in mortality, although Pebley et
al. (1979) and Rashad et al. (1993) are exceptions.
Economists, interested in both conceptual and statistical issues, have pursued
two related lines of research. Wolpin (1984) and Sah (1991) further refined the
dynamic theory that underlies modern economic models of insurance and re-
placement effects. Others developed multivariate techniques to circumvent some
of the problems that plague bivariate analyses (Schultz, 1976; Williams, 1977;
Olsen, 1980; Trussell and Olsen, 1983; Wolpin, 1984; Yamada, 1985;
Chowdhury, 1988; Pitt, 1994~. Subsequent empirical work, often using linked
macro- and micro-level data, generated a set of estimates of both the breastfeeding
and behavioral effects that are similar in magnitude and range to those reported in
the studies mentioned above (Hashimoto and Hongladarom, 1981; Lee and
Schultz, 1982; Anderson, 1983; Olsen and Wolpin, 1983; Okojie, 1991; Benefo
and Schultz, 1996; Panis and Lillard, 1993; Maglad, 1993, 1994~.
As noted above, surprisingly few attempts have been made over the past two
decades to weave these diverse strands of research into a coherent whole. A
notable exception is the comprehensive 1988 review by the United Nations Popu-
lation Division (United Nations Secretariat, 1988; Lloyd and Ivanov, 1988~. This
thoughtful synthesis clarified much about the evolution of the relationship be-
tween mortality and fertility over the course of the demographic transition. As
Lloyd and Ivanov argued, the demographic transition is in essence a transition in
family strategies: the reactive, largely biological family-building decision rules
appropriate to highly uncertain environments come eventually to be supplanted
by more deliberate and forward-looking strategies that require longer time hori-
zons. We take up several of the themes raised by Lloyd and Ivanov in the
following sections.
3Most such studies have used data that were collected under the World Fertility Survey program,
although some rely on census, panel, or ad hoc demographic surveys. Surprisingly, until the publica-
tion of this volume, analyses of data from the Demographic and Health Surveys on this question have
been almost nil.
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BARNEY COHEN AND MARK R. MONTGOMERY
THE DIFFICULTIES IN ANALYZING THE
MORTALITY-FERTILITY RELATIONSHIP
Perceptions and Agency
7
Women in pretransitional societies often express no clear personal prefer-
ence about the number of children they will bear (see, for example, Knodel et al.,
1987; van de Walle, 1992~. This lack of preference is sometimes termed "fatal-
istic," but on closer inspection can be understood as a rational stance vis-a-vis an
uncertain and contingent environment. Child survival is only one of many uncer-
tainties that must be faced in deciding family productive and reproductive strate-
gies (Castle, 1994~.
As improvements in child survival begin to occur in such settings, they may
reshape parental views in subtle but profound ways. Parents may begin to con-
ceive of the possibility of influencing the size of their own families, instead of
leaving such matters to chance or to the higher powers. Lloyd and Ivanov (1988)
termed this a "transitional effect," whereas UNICEF refers to it as the "confi-
dence factor" (UNICEF, 1991~.
Demographers know the concept as Coale's first precondition for fertility
transition, that fertility behavior must lie within the "calculus of conscious choice"
(Coale, 1973~. In their review, Lloyd and Ivanov hypothesized that the emer-
gence of conscious family planning, and the speed of its diffusion, depends on
both the age pattern of mortality in childhood and the degree to which risks can
be reduced by parental actions. Heavy infant but light child mortality makes
child survival more secure and predictable following infancy. When new health
behaviors are adopted, and these innovative health decisions are shown to exert a
perceptible influence on mortality risks, parents may be led to consider new,
more self-conscious strategies of family building in general.
The standard methods of economic and demographic inquiry are not at all
well suited to measuring such fundamental changes in psychological context.
Perceptions of mortality risks and of the efficacy of health interventions are
doubtless very difficult to elicit. Parents may not be able to articulate precisely
why they feel as they do, or be able to connect logically mortality risks to fertility
decisions in the schematic fashion that social scientists would prefer (see Knodel
et al., 1987, and Castle, 1994 for examples). In pretransitional settings, it would
surely prove difficult to extract meaningful information about the long-standing
preferences, beliefs, and modes of behavior that the participants themselves have
taken as given and not much examined.
Some evidence on these matters is available in the historical record for the
United States. For the period from the late eighteenth to the early twentieth
centuries (Preston and Haines, 1991; Dye and Smith, 1986; Vinovskis, 1991)
there are fascinating qualitative accounts of both continuity and change in mortal-
ity perceptions. The materials of Dye and Smith, largely drawn from women's
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8
INTRODUCTION
diaries, attest to an ever-present concern throughout the period with the possibil-
ity of child death. Adults also seemed to be intensely aware of the risks facing
themselves. Indeed, Vinovskis argues that adult mortality perceptions were much
inflated in relation to the empirical realities, in part because of the interests of
religious institutions in keeping their members focused on the afterlife.
Dye and Smith (1986) show that over the course of the nineteenth century,
childrearing came to be increasingly child centered in nature and became a task
increasingly assigned to mothers rather than one distributed among siblings, kin,
and other caretakers. Until the very end of the nineteenth century, however, this
transition in the definition of the quality of child care presented mothers with a
dilemma: They were being entrusted with safeguarding their children, and yet,
where mortality was concerned, lacked any effective means of doing so. The
result was an increasing tension between socially defined responsibilities and
technically constrained options. When the necessary medical breakthroughs were
finally made, according to Dye and Smith, women responded in both personal
and political terms. In personal terms, they enthusiastically adopted the new
medical techniques and adhered to advice; in political terms, they channeled their
pent-up energies to the creation of the Children's Bureau and other government
and public health institutions.
Although this account of the U.S. experience is only impressionistic, it raises
certain themes that have otherwise received very little research attention in demo-
graphic circles. There is the issue of perceptions of mortality risks as against the
empirical risks themselves. There is the distinction between high risks and risks
that, although high, might be controlled. There is an evolving definition and
redefinition of child quality, in which parental health investments, newly per-
ceived to be effective, eventually come to play a role. Finally, the decisive
actions are played out not only at the individual level, but also at the level of
political and public health institutions. All these factors figure into the develop-
ment of family-building strategies that stress design over fate, emphasize deeper
investment in child quality, and lead ultimately to lower fertility. The particular
circumstances were perhaps unique to one historical era in the United States, but
in broad outline have parallels elsewhere (e.g., Caldwell, 1986; Caldwell et al.,
1983; Caldwell and Caldwell, 1987~.
Preferences and Unwanted Fertility
The fertility response to mortality decline cannot be easily disentangled from
other factors that affect fertility preferences in general (whether for the number of
children, their sex composition, or their spacing) and the costs (whether mon-
etary, health related, or linked to spousal bargaining) that are associated with the
means of fertility control. Although debate continues about the measurement,
meaning, and depth of fertility preferences, one aspect is clear: Child replace-
ment effects are likely to be stronger among families that have not yet exceeded
their ideal family size and weaker among families that have already experienced
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BARNEY COHEN AND MARK R. MONTGOMERY
9
at least one unwanted birth. A notable feature of demographic research over the
past decade is the increasing appreciation of unwanted and unintended fertility
(see Bongaarts, 1997, for a review). The emergence of replacement effects is
thus linked, directly or indirectly, to the factors that shape fertility preferences,
govern the costs of fertility regulation, and thereby affect the proportion of fami-
lies that have yet to reach, or have already exceeded, their desired family sizes.
To a lesser extent, perhaps, insurance strategies are also affected by these factors.
Alternative Strategies Can Coexist
A further consideration is that the strategies of insurance and replacement
behavior, although conceptually distinct, have common roots in household con-
straints, preferences, and perceptions (see Wolpin, in this volume). A range of
such strategies can coexist within any given community or be adopted by a given
family at different points in its reproductive career (Preston, 1978b; Lloyd and
Ivanov, 1988~. Moreover, by constraining the options that are open to parents,
the program environment may affect their mix of strategies. For example, par-
ents might seek to combine replacement and insurance behavior where reversible
methods of contraception are unavailable (Bhat, in this volume).
The Nature of the Relationship Changes Over Time
In an earlier era, differences in fertility levels among developing countries
seem mainly to have reflected differences in social customs concerning such
matters as age at first marriage, divorce and remarriage, the length of breast-
feeding, sanctions on postpartum abstinence, and coital frequency. These social
and cultural influences in pretransition settings served to restrain fertility to lev-
els well below its biological maximum (Bongaarts, 1975~. The ensuing decline
in fertility can be viewed as a shift away from such "natural" fertility regimes
toward more self-conscious, parity-specific birth control, although changes in
age at first marriage associated with the rising educational achievements of
women have also played a significant role (Cleland, 1993~. Not surprisingly,
therefore, the relative importance of mortality effects also varies over the course
of the transition (Preston, 1975; Park et al., 1979; Frankenberg, in this volume;
Lloyd and Ivanov, 1988~.
Preston (1975) suggests that the extent to which dead children are replaced in
a family is approximately U-shaped, with populations at the highest and lowest
developmental levels exhibiting the strongest effects. Over the course of devel-
opment, he argues, the importance of the lactation interruption effect tends to be
reduced in relative terms, and the significance of behavioral responses propor-
tionately enhanced, as societies increasingly adopt parity-specific controls over
childbearing. Furthermore, as mortality conditions improve and the demand for
surviving children falls, parents are more likely to abandon pure insurance strat-
egies and substitute for them various forms of replacement behavior. Hence,
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10
INTRODUCTION
over the course of the demographic transition, the dominant mechanism changes
from a biological relationship associated with the truncation of breastfeeding to
behavioral replacement, passing through an intermediate stage in which insur-
ance strategies could be expected to hold sway.4
The Link to Human Capital Investments
We noted above the role that could be played in demographic transitions by
redefinitions of the norms governing child care and investments in the human
capital of children, with the emerging norms helping to reduce mortality and, in
addition, to raise the costs of continued high fertility. Among several forms of
human capital investment, the potential link between mortality and the motiva-
tion for investments in children's schooling merits special consideration.
Why might high mortality risks threaten children's schooling? The demo-
graphic reality is that the great majority of deaths occurring under age 20 are
those that occur before school age. Even in high-mortality environments, the
death of a school-age child is a relatively rare event. It would thus be unusual for
parental investments to be rendered fruitless by the death of a school child.
Unless there is a decided mismatch between parental perceptions of mortality and
the demographic realities, the roots of an association would need to be sought
elsewhere.
One possibility is that the conditions producing high infant and child mortal-
ity are also responsible for significant morbidity among school-age children.
Such morbidities would undermine children's energies and abilities to learn,
thereby reducing the payoffs that parents could expect to receive from their
schooling investments. Another possibility is that when higher parental fertility
is occasioned by higher child mortality, school-aged children are more often
called upon to serve as caretakers for their younger siblings or to assist their
mothers in household tasks. These additional duties may reduce the time that
children have available for schoolwork or even for school attendance, which
again could erode learning abilities and reduce the expected returns to additional
parental investments.
The perceived risks of adult mortality may play a role as well. Looking to
the future, and perhaps exaggerating the risks that they face, parents may fear that
they may not be able to sustain the resource flows needed to embark on what
might be, in context, an ambitious program of human capital investment in their
children. Not willing to risk the returns for themselves over the near term, and
being reluctant to raise their children's hopes only to have them later dashed,
parents might well conclude that a less ambitious strategy is in order. Moreover,
4In China, an extreme variant of the replacement mechanism sex-selective abortion is emerg
ing as a result of widespread availability of ultrasound and other diagnostic techniques (Zen" Yi et
aL, 1993; Goodkind, 1996).
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BARNEY COHEN AND MARK R. MONTGOMERY
11
one would expect that parental discount factors those subjective utility param-
eters that summarize how all future events are downweighted in salience by
comparison to the present would themselves be lower in highly uncertain envi-
ronments. The link between high mortality, environmental uncertainty in gen-
eral, and time orientation deserves serious study. Ainsworth et al. (in this vol-
ume) take up the issues in connection with mortality from AIDS.
Statistical Estimation Problems
In addition to the conceptual problems that have been described above, at-
tempts to isolate the effects of improved child survival on fertility face numerous
methodological difficulties (Schultz, 1976; Williams, 1977; Brass and Barrett,
1978~. For example, unmeasured third factors may well affect both fertility and
mortality, thus obscuring the true relationship between them. When micro-level
data are used, the discreteness of fertility measures and the nonlinearity of the
replacement effect induce an artificial correlation between fertility and child
mortality that can also affect estimates of behavioral relationships (Williams,
1977~. When macro-level time series data are used, the time dimension of the
analysis raises questions of autocorrelation (Brass and Barrett, 1978), which
would threaten the basis for inference. Furthermore, in many developing coun-
tries, estimates of fertility and mortality rates have been adjusted using indirect
estimation techniques that contain implicit assumptions about the nature of other
demographic conditions embedded within them (Brass and Barrett, 1978~.
Perhaps the most difficult estimation issue, however, is that causality be-
tween improved child survival and fertility runs in two directions (Galloway et
al., in this volume). It is now well established that the probabilities of survival are
lower for children born to teenagers, to older women, and to women of high
parity or closely spaced births (Hobcraft et al., 1983, 1985; Hobcraft, 1992~.
Hence, reductions in the number of births, particularly high-risk births, can be
expected to affect infant and child mortality rates.5 To circumvent this problem,
economists have long argued for the use of structural equations models (Schultz,
1988~. Such models require researchers to impose crucial identifying restric-
tions. Except in unusual cases, however, neither theory nor specific knowledge
of the relevant processes is sufficient to guide the choice of instruments (Schultz,
1988; Bhat, in this volume). Estimates of the effects of child mortality on fertility
tend to be disturbingly sensitive to such key details of model specification.6
5The direction of effect, however, is not always obvious (see the exchanges in Trussell and
Pebley, 1984; songaarts, 1987, 1988; Trussell, 1988).
6When put to the test, structural models often fail to reject the hypothesis that child mortality is
exogenous (see, for example, senefo and Schultz, 1996; Maglad, 1993; Panis and Lillard, 1993).
This may well reflect the low power of the tests involved, but could also indicate that fears of
statistical endogeneity have been exaggerated.
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28
INTRODUCTION
DISCUSSION
Twenty years ago, the most recent data available to assess the relationship
between mortality and fertility were from 1975. Since then, substantial improve-
ments in life expectancy have been recorded, state-sponsored family planning
programs were initiated and grew toward maturity, and fertility began to fall
across Latin America and Asia. In this chapter, we have described the recent
demographic situation with our principal focus being on the demographic changes
of the past two decades. The recent empirical record provides an outer core of
knowledge on the complex interrelationship between mortality and fertility.
Outside West Africa, virtually all developing countries have by now experi-
enced some order of joint decline of mortality and fertility. Their fertility de-
clines are the product of diverse social, economic, political, and cultural changes
and are shaped as well by a response to programs and mortality change. The
precise nature and specific contribution of each of these factors varies from one
society to another. Thus, at the macro level, a search for a simple and universal
rule linking the timing of mortality and fertility declines would seem to be futile.
At the micro level, what effect do mortality experiences and expectations
have on reproductive behavior? Numerous empirical studies have documented
that the death of a child reduces the probability that its parents will adopt contra-
ception and increases the likelihood of additional births. This is because deaths
and the expectation of deaths produce both behavioral and biological fertility
responses. Investigations of such effects depend crucially on the level (family
versus aggregate) and time frame of the analysis (Casterline, 1995~. Further-
more, as the chapters in this volume clearly demonstrate, the nature of the mortal-
ity-fertility relationship changes over the course of the demographic transition as
couples take greater control of their reproductive decisions and outcomes.
More has been learned about some mechanisms than about others. The
lactation interruption effect of a child' s death on fertility is now far better under-
stood than are the behavioral effects. The lactation mechanism is most important
in populations where breastfeeding is practiced widely but it remains important
even in populations that use modern contraception (Lloyd and Ivanov, 1988~. As
for the behavioral effects, most is known about replacement behavior, whether
studied by way of parity progression ratios or simultaneous equation models.
The chapters in this volume focus mainly on such replacement effects. These
studies strongly second the conclusion of the original Preston volume, that re-
placement is less than complete (Knodel, 1995~.
The mechanisms about which we continue to know the least are the insur-
ance effect and the "transition" or "confidence" effect. As noted above, research
into these mechanisms has been hampered by serious problems of conceptual-
ization and measurement, as well as by a lack of data. Progress in understanding
the insurance effect will require linking fertility change to community-level
changes in mortality; it will also require better models of individual decision
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BARNEY COHEN AND MARK R. MONTGOMERY
29
making and social learning. These were areas that Brass and Barrett (1978)
regarded as being out of reach in the mid-1970s, but ones that may benefit from
recent work on diffusion theory (see, for example, Casterline et al., 1987; Mont-
gomery and Casterline, 1996~.
To learn more about the onset of fertility declines, it is vital to understand the
transitional effect. Much of the pretransition literature points to the lack of
parity-specific control; either parents were unaware of the means to regulate their
fertility, saw little point in such regulation, or were constrained by social institu-
tions. Lloyd and Ivanov (1988) hypothesized that differences in the age pattern
of improvements in child survival could affect the size of the fertility response;
this important hypothesis remains untested.
Perhaps the most important policy implication of this work is for the interac-
tions among mortality, fertility, and family planning services. Twenty years of
lively debate in the demographic literature have yet to lay to rest the question of
whether family planning programs make an important independent contribution
to fertility decline (see, for example, Freedman and Berelson, 1976; Mauldin and
Berelson,1978;CutrightandKelly,1981;LaphamandMauldin,1987;Bongaarts
et al., 1990; Pritchett, 1994a,b; Bongaarts, 1994; Knowles et al., 1994~. The
research on mortality-fertility relationships reported in this volume shows that
the strength of the behavioral response can be affected by the extent and quality
of family planning services. For example, Bhat (in this volume) demonstrates
how the lack of reversible contraception has dampened the responsiveness of
fertility to improvements in child survival in India. In Costa Rica, Rosero-Bixby
(in this volume) found that, even in settings with moderately high levels of infant
mortality, the greater the supply of family planning services, the greater the
likelihood of fertility-limiting behavior. There is no evidence to suggest either
that child survival programs must precede family planning programs or vice
versa. Rather, the research discussed here suggests that child survival and family
planning programs play important complementary roles.
ACKNOWLEDGMENTS
This chapter has benefited from the discussion of participants at a seminar
entitled "Reevaluating the Link between Infant and Child Mortality and Fertil-
ity," which was organized by the Committee on Population in November 1995.
Nevertheless, the views and opinions in this chapter are solely those of the au-
thors and are not meant to reflect those of the National Research Council or the
other seminar participants. We are grateful to Caroline Bledsoe, Patrick Gallo-
way, John Haaga, Ken Hill, Bill House, Carolyn Makinson, and Faith Mitchell
for their comments on an earlier draft.
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30
INTRODUCTION
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Representative terms from entire chapter:
child mortality
