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OCR for page 227
7
The Relationshp Between Infant and Child
Mortality and Fertility:
Some Historical and Contemporary
Evidence for the United States
Michael R. Haines
INTRODUCTION
The demographic transition from high to low levels of fertility and mortality
is a defining characteristic of the development process. Historically, the precise
timing of both the fertility and mortality transitions has varied considerably.
Furthermore, there are important questions as to how fertility and mortality inter-
act during this process. The writings of Thomas R. Malthus (1830) are an early
example of this inquiry. One area of particular interest has been the relationship
of birth rates to infant and early childhood mortality, which has occasioned a
number of studies on developing nations since World War II (e.g., Hobcraft et al.,
1985; Potter, 1988; Lloyd and Ivanov, 1988~. There has also been some inquiry
into the historical experience of European nations that have passed through the
demographic transition (for a survey, see Galloway et al., in this volume), notably
in the context of the European Fertility Project (e.g., van de Walle, 1986) and
other projects using micro-data sources (e.g., Knodel, 1988:Chap. 14~. Finally,
there has been some work on more recent history of developing nations (Pamper
and Pillai, 1986~.
Much of the recent interest has centered on the following questions: Might
exogenously caused declines in infant and child death rates induce partially or
wholly offsetting declines in birth rates? Or will mortality-reducing programs,
valuable in and of themselves, simply exacerbate already high rates of population
growth? These questions form the focus in this volume.
There is, however, the complicating issue of reverse causality (or
endogeneity). Lower (or higher) mortality might induce lower (or higher) fertil-
ity, but it is well established that higher birth rates lead to higher infant and child
227
OCR for page 228
228 SOME HISTORICAL AND CONTEMPORARY EVIDENCE FOR THE UNITED STATES
mortality. This higher mortality is related to the effect on infants and children of
earlier weaning and reduced care from mothers. When the evidence is simply
bivariate in nature (as the zero-order correlations used to an extent in this chap-
ter), the causal paths cannot be disentangled. But treating them separately is
possible, and this is investigated here as well.
REVIEW OF THE LITERATURE:
EVIDENCE FOR THE UNITED STATES
The number of studies dealing with the interaction between fertility and
infant (or child) mortality for the United States is surprisingly small. This con-
trasts with historical research for Europe and for contemporary developing na-
tions. (See essays by Cohen and Montgomery and by Galloway et al., in this
volume.)
Among the few historical studies is a recent work using the Utah Population
Database of genealogies collected by the Mormon Church (Bean et al., 1992;
Lynch et al., 1985~. Bean et al. (1992) looked at the reasons why high fertility
rates may have resulted in high infant mortality rates for the western United
States in the nineteenth and early twentieth centuries. They propose three possi-
bilities (not mutually exclusive): the contagion and competition hypothesis, the
biological insufficiency hypothesis, and the maternal depletion hypothesis. The
first (contagion and competition) argues that more siblings disadvantage a recent
birth by way of increased risk of infectious disease and increased competition for
family resources. The second (biological insufficiency) links higher fertility to
higher-risk young mothers and hence higher infant mortality. This is both a
physiological and socioeconomic argument, since young mothers may not have
acquired as many childrearing skills. The third (maternal depletion) asserts that
higher fertility is related to more births among older women (age 35 and over)
who also have increased risk of infant death for both physiological and social
reasons. The results of the study show that, over time, birth intervals lengthened
and (by the late nineteenth century) ceased to have a major effect on infant
mortality. There was also some evidence for the biological insufficiency and
maternal depletion views as fewer births occurred to older women and as age at
marriage rose. Bean et al. (1992:344, Figure 1) also found that the infant mortal-
ity rate had a curvilinear relation to mother's age (highest at the youngest and
oldest ages), an inverse relationship to birth interval length (lowest at longest
intervals), an increasing relationship to birth order after the first two children, and
a strongly positive relation to parity. This covered the mid-nineteenth to the early
twentieth centuries.
A substantial group of studies was conducted earlier in this century by the
Children's Bureau using matched birth and infant death records over the period
1911-1915 for eight cities (Johnstown, Pennsylvania; Manchester, New Hamp-
shire; Saginaw, Michigan; Brockton, Massachusetts; New Bedford, Massachu
OCR for page 229
MICHAEL R. HAINES
229
setts; Waterbury, Connecticut; Akron, Ohio; and Baltimore, Maryland). These
were summarized in a monograph by Woodbury (1926) (see Table 7-1~. These
studies reported information on 22,967 births and 2,555 linked infant deaths for
which data on the families were obtained by interviews. Several relationships
were uncovered that echo the findings from the genealogical data. Infant mortal-
ity increased with birth order with the exception of a decline between the first and
second births. Infant mortality was also strongly inversely related to birth inter-
val. The characteristic curvilinear pattern of infant mortality and mother's age is
also seen in these data higher rates at the youngest and oldest ages. Father's
income (both total and per family member) had a strong inverse association with
infant mortality. These fascinating studies include some data on breastfeeding,
one piece of evidence pertinent to the influence of infant mortality on fertility.
Panel C of Table 7-1 presents information on breastfeeding by race and nativity.
Higher levels of artificial feeding were associated with higher infant mortality.
Greater incidence of breastfeeding partly offset the negative effects of lower
income among several of the foreign-born groups (Italian, Jewish, Polish) and
among blacks. Here we have some direct evidence that breastfeeding is associ-
ated with lower infant mortality risk, although the data are only suggestive. No
tabulations were presented, however, on differences in birth intervals for breast-
feeding versus artificial feeding, so it is not possible to see the joint association
with fertility.
A more recent set of matched birth and death records (from the National
Infant Mortality Survey of 1964-1966) have been analyzed by MacMahon and
his colleagues (MacMahon, 1974; MacMahon et al., 1973~. As of the 1960s,
some of the effects that were seen earlier still persist. The infant mortality rate
did increase with birth order, albeit not until parity six and above. Mother's age
still had the same curvilinear relation to probability of infant death. Also, a
previous infant or fetal death substantially increased the risk of subsequent infant
death. This may have been because of shorter birth intervals, but more likely it
reflected higher-risk mothers. This is a recurring finding in studies of developing
nations (e.g., Hobcraft et al., 1985~.
In general, however, work on this topic for the United States has been sparse.
There have been numerous studies of fertility and of infant mortality separately,
but few have attempted to link the two. Furthermore, previous studies have
stressed the path from fertility to mortality rather than that from infant and child
mortality to fertility.
THE DEMOGRAPHIC TRANSITION IN THE UNITED STATES
The study of the transition from high to low levels of fertility and mortality in
the United States is bedeviled by lacunae in the data. The United States was early
in the activity of taking national censuses (decennially from 1790), and the cen-
sus did provide useful published age and sex distributions from 1800 onward.
OCR for page 230
230 SOME HISTORICAL AND CONTEMPORARY EVIDENCE FOR THE UNITED STATES
TABLE 7-1 Mortality Analysis, Eight American Cities, 1911-1915
Panel A: Infant Mortality by Birth Order
Eliminating Influence of Mother's Age
Infant Ratio Ratio
Mortality to ActualExpected Actual/
Birth Order Rate Average DeathsDeaths Expected
1 104.6 94.1 652704.1 92.7
2 95.7 86.1 474538.6 88.0
3 104.6 94.1 348356.8 97.6
4 108.8 97.8 270266.5 101.2
5 118.8 106.8 210192.7 109.0
6 122.7 110.3 155141.2 109.7
7 136.8 123.0 126106.2 118.4
8 135.9 122.2 9279.9 115.2
9 146.8 132.0 6957.3 120.2
10 and over 181.5 163.2 159112.0 142.0
'otal 111.2 100.0 25552555.3 100.0
Panel B: Birth Interval since Preceding Birth (Baltimore only)
Birth Order/ Infant Ratio
Interval Mortality to
Length Rate Average
Birth order
First birth 94.8 91.6
Second and later 106.6 103.0
Interval length
1 year 146.7 141.7
2 years 98.6 95.3
3 years 86.5 83.6
4+ years 84.9 82.0
Total 103.5 100.0
OCR for page 231
MICHAEL R. HAINES
TABLE 7-1 (continued)
231
Panel C: Infant Mortality Related to Breastfeeding and Ethnicity
Ratio Actual/Expected Death
Infant
Artificial Income Mortality Partly Entirely
Ethnicity Feeding (%) <$650 (%) Rate Breastfed Artificial
White 25.2 39.6 108.3 139.2 410.5
Native 28.3 27.4 93.8 170.7 534.5
Foreign born 21.2 55.3 127.0 125.1 327.4
Italian 13.1 70.5 103.8 85.9 219.0
Jewish 11.3 44.5 53.5 46.9 290.9
French
Canadian 44.0 43.2 171.3 182.7 241.1
German 21.5 41.2 103.1 125.0 564.5
Polish 11.1 78.3 157.2 159.8 487.8
Portuguese 31.9 78.5 200.3 237.6 429.4
Other 23.2 45.0 129.6 102.3 325.4
Colored 19.7 81.9 154.4 82.2 315.8
Total 24.9 42.4 111.2 129.5 400.8
NOTE: Cities were Johnstown, Pennsylvania; Manchester, New Hampshire; Saginaw, Michigan;
Brockton, Massachusetts; New Bedford, Massachusetts; Waterbury, Connecticut; Akron, Ohio; and
Baltimore, Maryland. The study was based on samples totaling 22,967 live births and 2,555 infarct
deaths.
SOURCE: Woodbury (1926).
This allowed the study of fertility by way of the use of child/woman ratios
(Yasuba, 1962; Forster and Tucker, 1972; Okun, 1958; Schapiro, 1986~. As can
be seen in Table 7-2, these results point to a consistent decline in fertility from at
least 1800, as measured by child/woman ratios or by crude birth rates or total
fertility rates derived from them.
Unfortunately, collection of vital statistics was left to individual states and
municipalities, which resulted in tardy and uneven coverage. Massachusetts was
the first to begin this activity at the state level in 1842 and achieved relatively
good coverage by about 1855 (Abbott, 1897:714-715~. But the official Death
Registration Area was not formed until 1900 with ten states and the District of
Columbia, comprising about a quarter of the nation's population. The official
Birth Registration Area was not defined until 1915. Both were not comprehen-
sive until 1933 with the admission of Texas. Hence, what we know about mortal-
ity before the 1930s, and infant mortality in particular, is limited to smaller
OCR for page 232
232
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OCR for page 234
234 SOME HISTORICAL AND CONTEMPORARY EVIDENCE FOR THE UNITED STATES
geographic areas or to estimates. Some of these data are also presented in Table
7-2.
The United States was one of those cases of prior sustained fertility decline
in which fertility and infant mortality exhibited little or no relationship. From
Table 7-2 it is apparent that fertility had been falling since at least 1800. Mortal-
ity, in contrast, did not exhibit a sustained decline until about the 1870s. Table 7-
2 does not show an unambiguous decline in expectation of life at birth of the
infant mortality rate until 1880, although that date could have been an outlier with
a decline occurring earlier. This does not appear to have been the case, however.
Other mortality data, based on genealogies, and information on human stature,
point to deteriorating mortality in the several decades before the American Civil
War (Pope, 1992; Fogel, 1986), illustrated in Figure 7-1. The shorter life expect-
ancy is consistent with anthropometric data showing declining heights of West
Point cadets in the decades before the Civil War (Komlos, 1987~. Thus, the
United States constitutes a case in which, during the nineteenth century, fertility
was being controlled, mostly by adjustments in marital fertility (Sanderson, 1979),
whereas mortality came under control only very late. Under the circumstances, it
is not surprising that there was little relation between fertility and infant mortality
over time. It has been posited that only where there has been a prior decline in
infant and childhood mortality would there likely be any replacement or insur-
ance effect on fertility. If the relationship were from fertility to infant mortality
and if infant mortality were mostly subject to exogenous environmental influ-
ences (e.g., summer gastrointestinal infections and winter respiratory infections),
then the reduced birth ratios would have had only a damped effect on infant and
child mortality.
The official data for the United States (from 1909) are presented in Figure 7-
2. There it is apparent that the infant mortality rate was declining from 1915
onward, while fertility as measured by the general fertility ratio (births per 1,000
women aged 15-49) continued its decline until the baby boom. ~ The baby boom
may have retarded the decline in the infant mortality rate, which essentially
plateaued in the 1940s and 1950s, but it certainly did not raise it. In sum, there
appears to be little relationship between the birth rate and the infant mortality rate
in aggregate time series data for the United States from the early twentieth cen-
tury.
To go back to the nineteenth century requires narrowing the geographic
focus. Massachusetts is the best choice, because it had the longest continuum of
data of reasonable quality. Some of these data are presented in Figure 7-3 for the
{It should be noted that the Birth Registration Area was changing in composition from 1915 to
1933 as it was being augmented. The pattern for the original Birth Registration Area of 1915 was
virtually the same, however (tinder and Grove, 1947:Table 27).
OCR for page 235
235
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OCR for page 243
MICHAEL R. HAINES
243
a child death, have births in excess of the number that would be desired in the
absence of child loss (hoarding)? It has already been mentioned that it is of
interest whether reductions in infant and child mortality in developing nations,
undertaken in conjunction with general public health programs or with special-
ized maternal and child health initiatives, might help reduce fertility and the
population growth consequences of the mortality reduction (Lloyd and Ivanov,
1988:157-158~. Typically the observed replacement effects have been small, in
the range 0.1 to 0.4 for proportions adjusted for demographic and other covariates
(Lloyd and Ivanov, 1988:Table 6~.3
A method of estimating the pure replacement effect from basic data on
children ever born and children surviving (or children dead) for individual women
has been constructed by Olsen (Olsen, 1980; Trus sell and Olsen, 1983; see also
Mauskopf and Wallace, 1984~.4 The idea is that simply regressing the number of
births on the number of child deaths (i.e., CEBi = oc0 + oc~*Di where CEBi is births
to woman i and Di is child deaths to woman i, will yield a biased and inconsistent
estimate of replacement (octal. As an alternative, an instrumental variable (IV)
technique can be used. In stage one, children dead is regressed on the proportion
dead (i.e., Di = p0 + Hopi, where Pi is the proportion dead to woman i). At stage
two, the predicted value of child deaths from stage one is used in a regression
with births (i.e., CEBi = 70 + hi* Di, where Di is predicted child deaths). The
coefficient ~ is a good predictor of the replacement effect (net of hoarding) if the
number of births (CEB) and the proportion of children dead (P) are uncorrelated.
If this condition is not met, further corrections are necessary.
The basic correction uses the observed child mortality rate and the mean and
variance of the birth distribution (which can be calculated from the data) to
estimate a "true" replacement coefficient (t'). The final correction (IVEadj]) was
done taking Olsen's assumption that births and the proportion dead have a joint
bivariate lognormal distribution (Olsen, 1980; Trussell and Olsen, 1983~. The
corrected IV coefficient has been arbitrarily chosen in preference to the corrected
ordinary least-squares estimate.5
3In a survey of the literature to the mid-1970s, Preston (1975) found that the proportion of child
deaths replaced by a subsequent live birth was about 0.25 in high-fertility populations (Bangladesh,
Senegal, Morocco) where many women were not using contraception and were also breastfeeding. It
was even lower in populations in the early states of the fertility transition (Mexico, Peru, Colombia).
This rose again for countries with more advanced demographic transitions (e.g., costa Rica, Taiwan)
and was still higher for developed countries (e.g., 0.33 in France in 1962).
4For a discussion and critique of these models and methods, see the chapter by Wolpin in this
volume.
5Where there is observable heterogeneity in the underlying mortality risk (e.g., by geographic
area, rural or urban residence, racial or ethnic group), the estimates can be made separately for those
groups, areas, etc. Where the underlying mortality risk varies across individuals and groups but is
unobserved (e.g., by income), the Olsen correction may not be entirely sufficient. (See Wolpin in
this volume for a discussion of this.) Trussell and Olsen (1983) conducted some simulations of this
and found the effects to be small.
OCR for page 244
244 SOME HISTORICAL AND CONTEMPORARY EVIDENCE FOR THE UNITED STATES
Estimates of the replacement effect are presented in Table 7-6 for the simple
ordinary least-squares (OLS) regression of births on child deaths, the two-stage
instrumental variable approach (IV), and for the instrumental variable method
corrected for the correlation between births and the proportion death (IVEadj]~.6
The bias in the instrumental variable estimate of replacement (that is, (IV-IVEadj])
in Table 7-6) is a measure of the correlation between fertility and child mortality
and hence the extent to which high infant and child death rates could induce
higher birth rates, that is, hoarding. The assumption is that couples are aware of
the ambient child mortality rates. The results are given for women of all ages.
Analysis (not shown) was also done for women of age groups 25-29 through 45-
49. In addition, the population has been divided by race, nativity (native versus
foreign-born white), and residence (rural versus urban white) to account for
observed, known heterogeneity in underlying mortality risks (Preston and Haines,
1991~.
In general, the results show that the direct replacement effects (IVEadj]) were
quite modest in the United States around the turn of the century. Only about 10-
30 percent of infant and child deaths were replaced. The replacement coefficients
were shorter for younger women (not shown) who presumably had shorter birth
intervals in the earlier stages of family building and hence had less latitude to
make adjustments. The difference between the unadjusted IV estimate and the
adjusted IV estimate is an approximate measure of hoarding (that is, gross re-
placement minus direct replacement) (Olsen, 1980:440-441~. It was in the range
of 0.3-0.5 of a child, generally between 0.4 and 0.5 of a child per woman. This
results in a gross replacement effect (direct replacement plus hoarding) in the
neighborhood of 60-80 percent. Finally, there did not appear to have been any
clear differences in direct replacement of hoarding by race, nativity, or rural and
urban residence across the census decade. If anything, the tendency toward direct
replacement was smaller among older women in 1910 than in 1900, while the
propensity to hoard changed little (not shown).
Overall, it must be concluded that direct replacement was relatively modest
in the United States around 1900 and that there was still a substantial amount of
hoarding. This was taking place during a period of both declining fertility and
falling child mortality (see Table 7-2~. Because both fertility and mortality were
falling for a variety of reasons, there was little effect on natural increase from the
declining death rate among children.7 Also, results on replacement are not out of
line with contemporary estimates for developing countries (Lloyd and Ivanov,
1988~.
6Randal1 Olsen has kindly provided the author with a copy of his FORTRAN program to perform
the estimations.
7Natural increase remained relatively constant at 12.8 per 1,000 from the 1890s to the decade of
the 1900s (see Haines, in press, Table 1).
OCR for page 245
245
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OCR for page 246
246 SOME HISTORICAL AND CONTEMPORARY EVIDENCE FOR THE UNITED STATES
Some additional macro-level evidence is present in Table 7-7 in the form of
regressions of fertility on lagged and current infant mortality, along with other
variables. The upper panel uses the states of the United States in 1910. The
dependent variable is the estimated adjusted gross reproduction rate for 1910,
taken from the U.S. census of 1940 (Bureau of the Census, 1944~. In the first
regression, the gross reproduction rate for each state in 1910 is regressed on the
child mortality index for that state in 1900, along with the proportions nonwhite,
foreign born, and living in urban areas of 25,000 and over. Dummy variables for
regions were also included. In this case, birth rates should be responding to
previous levels of infant and child mortality; this was found. The sign was in the
expected positive direction, but the coefficient was not statistically significant.
The second equation substitutes the child mortality index in 1910 for that in 1900.
Again, the sign is positive, although the coefficient can be expected to be biased
because of simultaneous equations error (i.e., both the gross reproduction rate
and child mortality are endogenous). This is corrected in the third equation,
which is a two-stage least-squares estimation of the second equation. The instru-
ment chosen is the body mass index (kilograms of body weight per meters of
height squared) of World War I recruits for each state. This index is taken as an
indicator of health conditions in the 30 years prior to 1917-1918 (Davenport and
Love, 1921~. The coefficient on the child mortality index in 1910 was increased
but still remained statistically insignificant. The other independent variables
show that urban residence and living in the Northeast were associated with lower
fertility and that higher proportions of nonwhite and foreign born as well as
residence in the South were related to higher birth rates.
The final set of regressions repeats this exercise for the towns of Massachu-
setts in 1860 and 1885 and for the 54 largest cities in 1915. (Infant mortality
statistics ceased to be reported by town in 1890 and were published only for
larger cities thereafter.) At all three dates, the general fertility ratio (births per
1,000 women aged 15-49) was regressed on the lagged infant mortality rate,
urbanization, and the proportion of nonwhite and foreign born. (Proportion of
foreign born was not available by town in 1860.) The city population size was
used instead of the urban dummy variable used for 1860 and 1885 (equal to 1 if
the town was greater than 5,000 persons in 1860 and greater than 10,000 persons
in 1885~. In all cases, a 3-year average of vital statistics around the census dates
was used. The second equation at each date substituted the current for the lagged
infant mortality rate. Finally, the last equation at each date reestimated the
second equation with two-stage least-squares. The instrument selected was per-
sons per dwelling, deemed to be an index of crowding and possible source of
poor conditions for children.
For 1860, the coefficients on the infant mortality rate (lagged or current)
were positive. They were significant in the lagged and two-stage least-squares
specifications. The coefficient of infant mortality was again positive and signifi-
cant in the lagged specification for 1885, but it became negative in the contempo-
raneous equation. It was not significant in the simultaneous specification equa
OCR for page 247
MICHAEL R. HAINES
247
lion. Finally, the lagged specification also exhibited a positive and significant
effect of infant death rates on birth rates in 1915, although both the contempora-
neous specifications yielded insignificant though positive effects.
Overall, these macro-level results support the idea that infant mortality did
affect birth rates in the expected direction. For the Massachusetts results, the
ordinary least-squares regressions with lagged infant mortality revealed the ef-
fect, and it was strongest in 1915.
CONCLUDING REMARKS
This chapter began with an effort to explore the relationship of infant (and
early childhood) mortality to fertility in the United States over time. The pattern
both in time series and from cross-sectional data indicates, however, that the
United States is one of those complicated cases also observed by van de Walle
(1986) for Europe. Much of the current interest in this issue has focused on
recent experience of developing countries where infant and child mortality was
high and for which, in many cases, there was a decline in mortality at young ages
before, or concurrent with, the fertility transition. This was not the case for the
United States. Fertility was in decline from the late 1700s or early 1800s. The
overall sustained mortality transition of the modern era did not begin until about
the 1870s. For the best documented case Massachusetts infant mortality did
not begin a sustained decline until the 1890s, at a point when fertility had pla-
teaued after a period of reduction.
Although the time series patterns did not tend to indicate that fertility and
mortality were related in the nineteenth century, there is evidence that birth rates
responded to changes in death rates by the late nineteenth and early twentieth
centuries. Furthermore, the relationship strengthened over the early part of the
twentieth century as the decline in infant mortality proceeded rapidly. There is
also a suggestion of a lagged response of fertility to mortality change, indicating
hoarding (or insurance) behavior. This is confirmed by some cross-sectional
evidence for Massachusetts from the 1850s to the 1940s and for the country as a
whole from the early twentieth century. Two historical studies (Bean et al., 1992;
Woodbury, 1926) found evidence for a relationship for the American West in the
nineteenth and early twentieth centuries and for eight American cities, 1911-
1915. But the focus was largely on the link from fertility to infant mortality and
not the reverse causal path. The lack of an apparent historical association be-
tween fertility and mortality may have led to the paucity of studies, since basic
data had not suggested much to study.
Some new estimates of both direct replacement and hoarding from the 1900
and 1910 public use micro samples of the United States census also indicate that
the link from infant and child mortality to fertility was present, but was relatively
modest and in line with what has been observed in a number of developing
countries in recent decades. Only about 10-30 percent of all child deaths were
OCR for page 248
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OCR for page 249
249
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OCR for page 250
250 SOME HISTORICAL AND CONTEMPORARY EVIDENCE FOR THE UNITED STATES
directly replaced by births, although hoarding seems to have been more consider-
able. Gross replacement was thus in the range of 60-80 percent. Reductions in
infant and child mortality, such as were occurring in the twentieth century, would
thus have had a direct offset in reduced birth rates by about 25 percent. But there
would have likely been another indirect offset of up to 50 percent if hoarding
declined over time when parents gained greater assurance of child survival.
The relationship between fertility and mortality strengthened during the early
part of the twentieth century. The evidence for the United States from the 1 850s
to the 1940s supports the view that modest direct reductions in fertility can be
expected from reductions in infant and childhood mortality, but that more might
be expected as hoarding behavior diminishes. The United States is now at quite
low levels of fertility and mortality compared both with the past and with con-
temporary developing countnes, and it is not clear that the analysis of these
effects for the contemporary United States would yield much of interest in this
debate.
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253
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Representative terms from entire chapter:
child mortality
