Trends and determinants of infant and child mortality in Kerala

This serdes of unrefared dis- cwisiam gapers is InrenZec! rc prooide a n i n i t i a l circulatior of work prepared under the suspices of the Population a r Ruman R e ~ m r c e sDivision. Comments are therefode very welcome. n.e papers shctild not b e c i t e d without clearanc by the authors. The vievs espressed are'n- necessarily those of the World Bank Group Population and Human Resources Division Discussion Paper No. 82-2 TREhTDS AND DETERMIhTAP3TS OF INFANT AND C H I 1 9 MORTALITY IN K E W January 1982 Prepared by: The World Bank Washington, D . C . 20433  Abstract This paper e s t i m a t e s t h e trend i n nzo-natal, i n f a n t , and c h U d m o r t a l i t y r a t e s i n t h r e e d i s t r i c t s of Kerala and goes on t o a n a l y s e t k i r socio-economic d i f f e r e n t i a l s and determinants. Inasmuch a s t h e t h r e e saraple d i s t r i c t s a r e f a i r l y r e p r e s e n t a t i v e of t h e s t a t e a s a whole, t h e a n a l y s i s given h e r e a r e more o r l e s s v a l i d f o r Kerala S t a t e . Estimates of t r d s and t h e a n a l y s i s of t h e determinants given i n t h i s paper a r e f i r s t of the* Tafnd f o r Kerala, t h e d a t a a v a i l a b l e from o t h e r sources ( p r i n c i p a l l y SRS) are confined t o t h e r e c e n t d a t a on i n f a n t m o r t a l i t y r a t e . The a n a l y s i s shows t h a t t h e IF& i n Kerala is now about 50 wMch i s l e s s than h a l f i t s l e v e l i n t h e state i n 1955-60 (107) o r t h e c u r r e n t l e w d i n o t h e r p a r t s of I n d i a ( 125). The neo-natal m o r t a l i t y i s about 40 and d u d w r t a l i t y r a t e (1970-75) i s 32. The IMR corresponds t o a n expectlatiom o f l i f e a t b i r t h of about 65 y e a r s i n West Model L i f e Tables. The e x t e n t of m o r t a l i t y d e c l i n e has been l a r g e s t i n t h e childhood a g e s (64% during 1958-73) and least during t h e f i r s t month a f t e r b i r t h (32% during 1958-73). The IMR declined by 45 percent during t h e same period. M o r t a l i t y r a t e s a r e higher among c h i l d r e n of mothers with no schooling, mothers who belong t o scheduled c a s t e s , mothers i n househoEds Flrfth no protected t o i l e t f a c i l i t i e s , e t c . Multiple Regression a n a l y s i s i a c a t e s t h a t i n f a n t m o r t a l i t y (and n e o l l a t a l m o r t a l i t y ) i s s i g n i f i c a n t l y a s s o d a t e d with mothers education ( i n v e r s e r e l a t i o n s h i p v i t h education), Caste (seheduned c a s t e s have higher m o r t a l i t y ) , year of b i r t h ( r e c e n t b i r t h s have l o v e r m o r t a l i t y ) , s i n g l e o r twin s t a t u s (twin b i r t h s a r e a s s o c i a t e d wfth h i g h e r m o r t a l i t y ) , and t o t a l household expenditure (higher expenditure h o u s e b f d s have lower m o r t a l i t y ) . IMR d i d not show s t a t i s t i c a l l y s i g n i f i c a n t a e s m c i a t i o n with t h e land owned by t h e nousehold, by t h e source of water supply ta the house, t o i l e t f a c i l i t y and per c a p i t a household expenditure. On t h e -her hand, c h i l d m o r t a l i t y showed s t r o n g a s s o c i a t i o n with economic f a c t o r s <per c a p i t a expenditure, l a n d , water supply, t o i l e t f a c i l i t y and t o t a l h o u e b l d expenditure) and r e l a t i v e l y weak ( i n s i g n i f i c a n t ) a s s o c i a t i o n v i t h cas-, ordler of b i r t h , and s i n g l e o r twin s t a t u s of the b i r t h . In general, socio-ezonomic f a c t o r s explain only a s m l l p e r a x t t of the i n f a n t m o r t a l i t y d i f f e r e n t i a l s a t household level. Absence of vadablesi on h o s p i t a l u t i l i z a t i o n , e s p e c i s l l y f o 5 a n t e n a t e l and post n a t a l c a r e , l o proposed i n the paper a s t h e main reason f o r the low explanatory power of ehe r e g r e s s i o n model used i n t h i s study. It i s recanmended t h a t such v a r h M m i be included i n f u t u r e researches on determinants of i n f a n t and c h i l d m o r t a l i t y . - - From the mathodological point of view, t h e paper d e m o n s t r a t e tet: the o f t e n noted p o s i t i v e a s s o c i a t i o n between i n f a n t m o r t a l i t y r a t e and! per c a p i t a expenditure iriDIndia i s due t o the c i r c u l a r causation - inverse = r e l a t i o n s h i p between ancome (expenditure) and m o r t a l i t y , and i n v e r s e * r e l a t i o n s h i p between m o r t a l i t y and household s i z e r e s u l t i n g i n a posirfLve ' a s s o c i a t i o n between m o r t a l i t y and per c a p i t a expenditure. The paper discourages the use of per c a p i t a expenditure i n demographic a n a l y s i s , p a r t i c u l a r l y a o r t a l i t y analysis.  TABLE OF CONTENTS Page Number Preface .................................................... i Introduction ............................................... 1 Mortality Trend ............................................ 2 ............................... Socio-Economic D i f f e r e n t i a l s 4 Parity of the Mother .................................... 4 Caste ................................................... 5 Education ............................................... 5 Land Ownership .......................................... 6 ..................................... Sanitary F a c i l i t i e s 6 Household Expenditure ................................... 6 DeternLnants of Mortality .................................. 11 Infant Mortality ........................................ 12 Neo-natal and Child Mortality ........................... 16 Anomaly of the Relationship between Per Capita Household Expenditure and Infant Uortality Rate .......... 17  LIST OF FIGURES AND TABLES Page Number F i g u r e 1: I n f a n t M o r t a l i t y Rate by Order of Birth.................-..--..-............ 6a Table 1: Neo-na t a l , I n f a n t and c h i l d M o r t a l i t y Rates, 3 D i s t r i c t s of Kerala ................. 2 Table 2: E s t i m a t e s of Excpectation of L i f e a t a t B i r t h based on West Model L i f e Tables and Observed IMR, and c h i l d , b - M o r t a l i t y Rates: 3 D i s t r i c t s of Kerala.. .... 3 E Table 3: Neo- natal, I n f a n t and c h i l d Mortality, by P a r i t y of Mother.......................... 7 Table 4: Neo- natal, I n f a n t and c h i l d M o r t a l i t y by C a s t e and Religion................-..-.... Table 5: Neo- natal, I n f a n t and c h i l d M o r t a l i t y by e d u c a t i o n a l a t t a i n m e n t of mother.......... Table 6: ............. Neo- natal, I n f a n t and c h i l d m o r t a l i t y by household ownership of land.. Table 7: Neo- natal, I n f a n t and c h i l d m o r t a l i t y by t o i l e t f a c i l i t i e s i n t h e household.. ...... Table 8: Neo- natal , I n f a n t and c h i l d m o r t a l i t y by s o u r c e of water supply.................... Table 9: I n f a n t a n d c h i l d m o r t a l i t y by House- Hold Expenditure....................-........ Table 10: P r o b i t a n a l y s i s of s u r v i v a l s t a t u s d u r i n g f i r s t year of each birth.............. Table 11: 8 1 Ordinary Least Square Regression ............. Table 12: P r o b i t a n a l y s i s of neo- natal and c h i l d - - s u r v i v a l s t a t u s of each birth................ ? 'Table 13: D i s t r i b u t i o n of Households by T o t a l - i i Household expenditure i n each PCE class...... s a b l e 14:. D i a t r i b u t i o n of s e l e c t e d households by f a m i l y s i z e , c h i l d r e n ever born and c h i l d r e n dead of household...................  Preface i n i s i s second i n a s e r i e s of r e p o r t 6 on t h e World Plank - Bureau of Economics a n d S t a t i s t i c s (Trivandrum) r e s e a r c h p r o j e c t on d e t e r m i n a n t s of f e r t i l i t y d e c l i n e i n Kerala. Other r e p o r t s on t h e p r o j e c t a r e being p r e p a r e d by t h e Bureau i n Trivandrum. The Kerala s t u d y i s p a r t of a l a r g e r World Bank r e s e a r c h p r o j e c t e n t i t l e d "Determinants of F e r t i l i t y Decline i n S r i Lanka and South India" (World Bank Research P r o j e c t No. 671-70) co- sponsored by t h e World Bank, t h e United Nations' Fund f o r P o p u l a t i o n A c t i v i t i e s (UNFPA), and t h e Governments o f I n d i a and S r i Lanka. The s t u d y i n Kerala w as c a r r i e d o u t by t h e Burean of Economics and S t a t i s t i c s , Government of Kerala, T r ivandrum, under t h e d i r e c t i o n of Drs. P.A. Nair and R.S. Karup. M r . P.S. Gopinathan Nair was t h e officer- in- charge. Data f o r t h e a'iudy were c o l l e c t e d from a random sample of 3,000 households from U O v i l l a g e s s e l e c t e d a t random from 3 s e l e c t e d d i s t r i c t s : P a l g h a t , Ernakulam and Alleppey. The f i e l d work was c a r r i e d o u t d u r i n g January- June, 1980. The s t u d y used 10 s c h e d u l e s t o c o l l e c t d a t a . These a r e l i s t e d below: I. Household Schedule 11. Ever-married women, marriage h i s t o r y 111. Ever-married women, m a t e r n i t y h i s t o r y IV . Ever-married women, c o n t r a c e p t i v e knowledge V. Ever-married women, f e r t i l i t y r e g u l a t i o n VI. Ever-married women, work h i s t o r y V I I. Ever-married women, husbands ' background VIII. Never-married men 20-39 y e a r s 1 a IX . Never-married romen 18-34 y e a r s X. - C u r r e n t l y marri ?d men 20-39 y e a r s .a T h i s r e p o r t i s based on d a t e of b i r t h and d a t e of d e a t h ( f o r t h o s e who d i e d ) of about 9400 b i r t h s , born between 1950 and 1980 t o e v e r - m r r i e d women interviewed i n t h e curve!?. S t s main f o c u s i s t o e s t i m a t e i n f a n t and c h i l d m o r t a l i t y t r e n d s and d i f i ' e r e a t i a l s i n t h e t h r e e survey d i s t r i c t s a n d a n a l y s e t h e i r determinants.  TRELDS AND DETLRMINANTS OF INFANT AND CHILD MORTALITY I N KEXALA - INTRODUCTION . K e r a l a i s r e p o r t e d t o have f a i r l y good h e a l t h c o n d i t i o n s and Xaw mortality rates. T h i s i s supported by t h e a v a i l a b l e m o r t a l i t y d a t a . Asrong F t h e v a r i o u s s t a t e s of I n d i a , Kerala has t h e lowest death r a t e . I n 1977, t h e 8 F p c r u d e d e a t h r a t e i n Kerala was e s t i m a t e d t o be 7.5 p e r 1 , 0 0 0 p o p u l a t i c - and $. ! i n f a n t m o r t a l i t y r a t e 50 p e r 1,000 l i v e b i r t h s ; f o r I n d i a a s a whole t h e 6 a r C - c o r r e s p o n d i n g r a t e s were 13 and 129 r e s p e c t i v e l y . Thus, t h e m o r t a l i t y tates i n K e r a l a are indeed s u b s t a n t i a l l y lower t h a n t h e r e s t o f I n d i a . O t h e r t h a n t h i s o v e r a l l l e v e l , l i t t l e i s known a b o u t t h e m o r t a l i t y pattern i n the state: how i t v a r i e s from one r e g i o n o f t h e s t a t e t o a n o t h e r , how i t d i f f e r s between v a r i o u s socio- economic groups, e t c . I n o t h e r words, a l t h o u g h v e have f a i r l y good e s t i m a t e s o f t h e l e v e l of m o r t a l i t y i n K e r a l a , l i t t l e i s known about i t s d e t e r m i n a n t s . Even what w e know a b o u t t h e level comes from s i n g l e s o u r c e , namely, t h e sample r e g i s t r a t i o n system (SRS),, w h i c h i s n o t uniformly r e l i a b l e . Whether SRS d e a t h r a t e s a r e r e l i a b l e f o r KeraXa i s s q u e s t i o n v h i c h h a s n o t been p r o p e r l y examined on t h e b a s i s o f i n d e p e n d e n t sources of data. T h i s paper a t t e m p t s t o f i l l some of t h e g a p s i n o u r hama- l e d g e a b o u t t h e m o r t a l i t y s i t u a t i o n i n Kerala. I n particular, i t provides a n e s t i m a t e of t r e n d i n n e o a a t a l , i n f a n t and c h i l d m o r t a l i t y r a t e i n t h r e e dis- t r i c t s o f K e r a l a f o r r e c e z t p e r i o d s and a n a n a l y s i s of t h e i r socio-econ&cr d i f f e r e n t i a l s from t h e p o i n t s of view o f t h e i r magnitudes and determinants. - - Several authors, analysing Indian mortality d i f f e r g n t i a l s , h a v e L pointed o u t t h e observed p o s i t i v e r e l a t i o n s h i p between i n f a n t m o r t a l i t y rate r and p e r c a p i t a household e x p e n d i t u r e . T h i s paper examines t M s r e l a t i o n s h i p i n d e p t h and t e s t s one o f t h e h y p o t h e s i s p u t f o r t h a s e x p l a n a t i o n s f o r the  peculiar relationship. M o r t a l i t y Trend The Kerala f e r t i l i t y survey h a s c o l l e c t e d i n f o r m a t i o n about t h e d a t e of b i r t h o f about 9400 c h i l d r e n born between 1950 and 1980, t h e i r s u r - v i v a l s t a t u s i n 1980 (dead o r a l i v e ) , and t h e d a t e of d e a t h o f t h o s e who d i e d . These d a t a a r e s u f f i c i e n t t o e s t i m a t e n e o n a t a l m o r t a l i t y , i n f a n t m o r t a l i t y and c h i l d m o r t a l i t y r a t e . These e s t i m a t e s a r e shown i n Table 1. For t h e p e r i o d 1975-80 t h e IYR i s e s t i m a t e d t o be 46 which i s l e s s t h a n t h e SRS e s t i m a t e of 50 by 4 p o i n t s . There i s no reason bihy P a l g h a t , Ernakulam and Alleppy d i s t r i c t s should be r e p r e s e n t a t i v e of Kerala s t a t e a s a whole; t h e a v e r a g e f o r t h e t h r e e d i s t r i c t s could indeed be lower t h a n t h e S t a t e average. But t h e c l o s e n e s s of t h e two e s t i m a t e s f o r t h e 1970-75 period and d i f f e r e n c e i n 1975-80 make one wonder whether t h e e s t i m a t e from t h e f e r t i l i t y s u r v e y i , s a n under- e s t i m a t e f o r t h e more r e c e n t p e r i o d . It probably i s , but u n l i k e l y t o be by a l a r g e margin ( n o t more t h a n one o r two p o i n t s ) . Table 1: NEONATAL, INFANT AND CHILD MORTALITY RATES, 3 DISTRICTS OF KERALA FERTILITY SURVEY DATA SRS i Neonatal Period 111fant Child Infant [ Mortality Mortality 1975-80 41 46 - 50.1 (1977) 1970-75 50 59 32 60.9 (i971) 1965-70 52 68 42 74.0 (1965-67) 1960-65 62 83 57 -- Before 1960 73 - 107 88 120 1951-60) A l l Years 55 73 47 -- I Source: S t a t i s t i c s f o r Planning, Kerala F e r t i l i t y Survey. For SRS r a t e s s e e - - 1980. The D i r e c t o r a t e of Economics and S t a t i s t i c s , Keralc, 1980 Table 1.14, p.4  I n a d d i t i o n t o IMR, t h e survey a l s o g i v e s i n f o r m a t i o n on t h e t r e n d of neo- natal m o r t l i t y , and c h i l d m o r t a l i t y r a t e (4q1). Declines a r e evident - i n a l l t h e s e r a t e s , b u t t h e l a r g e s t d e c l i n e has been i n t h e c h i l d m o r t a l i t y r a t e , lesser d e c l i n e i n IMR and l e a s t d e c l i n e i n neo- natal mortall.ty. Thus, t h e m o r t a l i t y r a t e s which a r e most i n f l u e n c e d by environmental f a c t o r s a r e t h e ones which showed t h e g r e a t e s t d e c l i n e . 1 The l i f e e x p e c t a t i o n s (based on West model of l i f e t a b l e s ) c o r r e s - ponding t o t h e e s t i m a t e d i n f a n t and c h i l d m o r t a l i t y a r e g i v e n i n Table 2. Table 2: ESTIMATES OF EXPECTATION OF LIFE A" BIRTH BASED ON WEST MODEL LIFE TABLES AND OBSERVED IMR, AND CHILD MORTALITY RATES: 3 DISTRICTS OF KERALA L i f e Expectancy Based On: Period m 4q1 1975-80 65.6 - 1970-75 62.6 59.0 1965-70 60.6 55.8 1960-65 57.4 51.8 -Before 1960 52.6 44.9 The e x p e c t a t i o n of l i f e a t b i r t h i n t h e t h r e e d i s t r i c t s was 65.6 y e a r s d u r i n g 1965-80. I t i n c r e a s e d c o n s i s t e n t l y from about 5 3 y e a r s i n 1955-60 L t o '66'years i n 1975-80, a 13- yeat i n c r e a s e i n a 20 o r 25- year period. This i s not i m p o s s i b l e , and is, i n f a c t , t h e expected r a t e . Comparison between t h e e s t i m a t e of l i f e expectancy from IMR and 4q 1 indicates t h a t , f o r a given i n f a n t m o r t a l i t y r a t e t h e c h i l d moPtality i n Kerala B I was much t o o high. However t h e d e c l i n e i n c h i l d m o r t a l i t y was f a s t e r t h a n t h e d e c l i n e i n i ~ f a n t m o r t a l i t y r a t e and, t h e r e f o r e , t h e gap between t h e two i s narrower now t h a n i n the past. S i m i l a r t r e n d s a r e observed i n =any o t h e r p o p u l a t i o n s a l s o i n r e c e n t y e a r s , Egypt f o r example. Socio-Econcmic D i f f e r e n t i a l s M o r t a l i t y r a t e e vary by socio-econom5.c c h a r a c t e r i s t i c s o f t h e hous*hold. A few of t h e s e a r e d i s c u s s e d below without t r y i n g t o i s o l a t e t h e independent e f f e c t s o f t h e s e v a r i o u s f a c t o r s . T h i s i s done i n t h e re- g r e s s i o n a n a l y s i s which follows t h i s s e c t i o n . --- P a r i t y of t h e Hother Children of women who have a l a r g e number of c h i l d r e n tend t o ex- p e r i e n c e higher m o r t a l i t y t h a n c h i l d r e n of vomen with fewer c h i l d r e n . Thus, I R ( d u r i n g 1970-80) among c h i l d r e n of mothers w i t h 5 c h i l d r e n o r more was M 73 w h i l e t h e I M R among c h i l d r e n of mothers w i t h 2 o r less c h i l d r e n w a s o n l y 23. The r e l a t i o n s h i p between p a r i t y and m o r t a l i t y r a t e i s c o n s i s t e n t l y p o s i t i v e nct o n l y f o r I M R , b u t a l s o f o r neo- natal or and c h i l d m o r t a l i t y . Over t h e y e a r s , ( b e f o r e 1970 and a f t e r 1970) t h e l e v e l has d e c l i n e d , but t h e p a t t e r n of r e l a t i o n s h i p between p a r i t y and m o r t a l i t y r a t e was u n a f f e c t e a . This t a b l e however, cannot answer t h e q u e s t i o n whether h i g h p a r i t y caused ~ ~ i l et h i s seems t o be t h e c a s e , t h e r e v e r s e high i n f a n t and c h i l d m ~ r t a l i t y .W c a u s a t i o n ( h i g h e r i n f a n t m o r t a l i t y causing higher f e r t i l i t y ) i s a l s o p o s s i t l e . A p a r t i a l check on t h i s q u e s t i o n i s given i n F i g u r e 1 where M IR ? - i s shown a g a i n s t G i r t h o r d e r . The M I R i s higher among t h e 1st o r d e r b i r t h s and among b i r t h e e r s 6 and above, and i s lowest among t h e second o r d e r I births. The d e c r e a s e ( o v e r time) i n IMR i s more n o t i c e a b l e among t h e lower order b i r t h s . I n f a c t , among t h e 8 and 9 o r d e r b i r t h s t h e r e is no d e c l i n e a t all.  Caste Scheduled c a s t e s and Ezawas have r e l a t i v e l y h i g h e r morr.ality r a t e s t h a n t h e o t h e r . c a s t e and r e l i g i o u s groups (Table 4 ) . The Scheduled c a s t e s P have t h e h i g h e s t m o r t a l i t y r a t e . M I n 1970-80 t h e i r I R and c h i l d m o r t a l i t y r a t e s were twice a s much a s t h o s e of t h e C h r i s t i a n s , but t h e m o r t a l i t y d e c l i n e among them h a s a l s o been s u b s t a n t i a l . For example, t h e 1 M : R among t h e scheduled c a s t e s i s e s t i m a t e d t o have d e c l i n e d from 142 ( b e f o r e 1970) t o 76 (1970-80), a f o r t y s i x percent r e d u c t i o n . S y r i a n C h r i s t i a n s have t h e lowest m o r t a l i t y r a t e . A comparison of t h e i r r a t e s w i t h th\t o f t h e Nairs i s p a r t i c u l a r l y noteworthy. In the past, t h e N a i r s had, on t h e whole, lower m o r t a l i t y r a t e s , but i n r e c e n t y e a r s t h e r a t e s f o r t h e C h r i s t i a n s a r e lower. Thus, t h e r a t e of d e c l i n e i n m o r t a l i t y has been f a s t e r among t h e C h r i s t i a n s t h a n among t h e Nairs. The r e a s o n s f o r t h i s d i f f e r e n t i a l s are n o t q u i t e e v i d e n t ; probably t h e u t i l i z a t i o n of medical f a c i l i t i e s , p a r t i c u l a r l y f o r m a t e r n i t y , could be h i g h e r among t h e C h r i s t i a n s than among t h e Nairs. Education I n f a n t and C h i l d m o r t a l i t y r a t e s a r e i n v e r s e l y r e l a t e d t o mothers education. I n r e c e n t y e a r s , t h e chance of a c h i l d dying d u r i n g L * s t h e f i r s t y e a r of i t s l i f e i s twice a s high i f i t s mother i s n o t educated t h a n i f t h e mother h a s some schooling. - M o r t a l i t y had d e c l i n e d i n a l l e d u c a t i o n a l '8 groups, b u t t h e maximum d e c l i n e occured amongzchildren born t o malthers who had 1 - 4 y e a r s o f echooling. - It may n o t be &mere c o i n c i d e z c e t h a t i c i s . e x a c t l y among t h i s group o f women t h a t f e c t i l i t y d e c l i n e has a l s o been :ax imum . Land Ownership The r e l a t i o n s h i p between land ownership and m o r t a l i t y i s n o t v e r y consistent. A p r i o r i one should expect a n e g a t i v e r e l a t i o n s h i p : children born i n households w i t h l i t t l e land should e x p e r i e n c e h i g h e r m o r t a l j t y r a t e s t h a n c h i l d r e n born i n households w i t h l a r g e r l a n d holdings. This pnttern i s a o t always observed. For example, t h e IMR of 1970-80 shows a weak p o s i t i v e r e l a t i o n s h i p b u t t h a t of t h e p e r i o d b e f o r e 1970 shows t h e expected negative relationship. T h i s somewhat i n c o n s i s t e n t r e l a t f m s h i p mag' be due to t h e n a t u r e of t h e two s e t s o f d a t a . at Land ownership r e f e r s t o 0 ~ e r S h i p t h e time of t h e s u r v e y , b u t t h e i n f a n t and c h i l d m o r t a l i t y r e f e r s t o a p r i o r period: 1970-80 o r b e f o r e 1970. I n Kerala, t h e r e have t e e n some s i g n i f i c a n t changes i n l a n d ownership i a r e c e n t years. Sanitary F a c i l i t i e s Houreholds have been c l a s s i f i e d according t o whether t h e house h a s f l u s h t o i l e t s , ESP s l a b t o i l e t s o r whether t h e members use "compound" e t c f o r t o i l e t needs. The m o r t a l i t y r a t e s of c h i l d r e n born i n t h e d i f f e r e n t t y p e s of households show t h e expected d i f f e r e n t i a l s : housebolds w i t h p r o r e c t e d t o i l e t f a c i l i t i e s ( f l u s h and ESP s l a b ) have d i s t i n c t l y lower m o r t a l i t y r a t e s than households whrch use "compounds" f o r t o i l e t needs. However, s o u r c e o f water supply f o r t h e household i s n o t a s i g n i f i c a n t d i s c r i m i n a t o r y f a c t o r . The IMR i n 1975-80 o f households w i t h p i p e s was 50, t h o s e w i t h w e l l s was 56, - J ' and t h o s e which u s e o t h e r s o u r c e s of water supply was b b . L - - Household Expenditure B 7 The t o t a l houichold e x p e n d i t u r e and p e r c a p i t a e x p e n d i t u r e ( t o t a l (I - monthly hollsehold e x p e n d i t u r e divided by t h e number of persons i n t h e house- hold) may have d i f f e r e c t r e l a t i o n s h i p with m o r t a l i t y . There a r e problems w i t h e i t h e r usage a s a measure of poverty. T h e r e f o r e , we have g i v e n t h e a n a l y s i s u s i n g t o t a l a s w e l i a s per c a p i t a a x p e n d i t u r e .  The r e l a t i o n s h i p hstween i n f a n t m o r t a l i t y and household e x p e n d i t u r e i s g i v e n i n Table 9. The top p a n e l g i v e s t h e r e l a t i o n s h i p with t o t a l monthly e x p e n d i t u r e and t h e bottom panel g i v e s t h e r e l a t i o n s h i p w i t h p e r c a p i t a monthly expenditure. On t h e whole i n f a n t m o r t a l i t y d e c r e a s e s w i t h increases1 i n household expenditure. The d e c l i n e has been more s y s t e m a t i c i n t h e p a s t ( b e f o r e 1970 f o r which period we have a l a r g e r sample s i z e ) than i n t h e most r e c e n t period. The r e l a t i o n s h i p w i t h per c a p i t a household ixpenditure i s l e s s regular. For example, a s p e r c a p i t a e x p e n d i t u r e i n c r e a s e s from below Rs. 30 t o above Rs. 120, IMR d e c r e a s e s from 9 3 t o 64, t h e n i n c r e a s e s t o 74 and decreases again t o 61. Decomposition of t h e r a t e s t o t h a c f o r t h e p e r i o d s b e f o r e 1970 and a f t e r 1970 does not make much of a d i f f e r e n c e ; i r r e g u l a r i t i e s a r e observed f o r b o t h t h e periods. Table 3: NEO-NATAL INFANT AND CHILD MORTALITK BY PARITY OF MOTHER Parity Neo-Na ta 1 - IMR Child M o r t a l i t y Before 1970. 80 Before 1970-80 Before 1970-75 1970 1970 1970  Table 4: NEO-NATAL, IhTANT AND CHILD MORTALITY BY (2ASTE AR9 RELIGION - Caste Neo-Natal - IMR Child M o r t a l i t y Before 1970-80 Before 1970-80 Before 1970-75 1970 1970 1970 Scheduled 99 52 Nairs 43 38 Ezawas 77 48 96 59 53 40 Syria3 Christians 56 - 33 69 35 45 7 Latin Christians 49 24 61 53 73 32 Muslims 45 27 74 38 78 34 Table 5: NEO-NATAL, INFANT AND CHILD MORTALITY BY EDUCATIONAL ATTAINMENT OF MOTHER Years of Neo-Natal IMR - Child M o r t a l i t y Schooling I of ~ o t h ' e ; Before 1970-80 Before 1970-80 Before 1970-75 1970 1970 1970  T a b l e 6: NEO-NATAL, INFANT AND CHILD MORTALITY BY HOUSEHOLD OWERSEIP O F LAND Land Owned ' By The Neo-Natal - M IR Child Mortality 1 Household E, ? - Before 1970-80 Before 1970-80 Before 1970-75 1 (Cents) 1970 1970 1970 - 1 Cent = 1 o f a n a c r e . 100 i Table 7: NEO-NATAL, INFANT AND CHILD MORTALITY BY . L TOILET FACILITIES I N THE HOUSEHOLD i - - - - Toilet Neo-Na t a l - IMR Child Mortality F - a c i li t y - 2 - Before 1970 1970-80 Before 1970 1970-80 Before 1970 ' 1970-75 1 0 , Flush 37 38 62 46 25 I - 26 ESP S l a b 56 34 59 b1 41 13 Compound e t c . 70 45 93 56 71 36  Table 8: NEO-NATAL, INFANT AND CHILD M ORTALT I Y BY SOURCE OF WATER SUPPLY Source Neo-Natal - M I R Child Mortality Before 1970-80 Before 1970-80 Before 1970-75 1970 1970 1970 Table 9: INFANT AND CHILD MORTALITY BY HOUSEHOLD EWENDITUR E Monthly ~ousehoid Infant Mortality Rate Child Mortality Expenditure Before 1970 All Before 1970 All 1970 -80 Periods -- 1970 -75 Periods Total Household Expenditure L A l l Classes 85 53 73 61 33 56 i -- --- *- - - - ---- F l - - i *1 - r ' Per Capita Household Expenditure 30 328 47 93 47 25 58 30 - 49 SO0 57 81 67 41 59 50 - 59 180 41 64 80 36 69 60 - 79 75 72 74 68 36 60 80 - 119 80 32 66 49 16 42 120+ 59 65 61 17 23 18 A l l Classes 85 53 73 61 33 54  DETERMINANTS OF INFANT AND CHILD MORTALITY The p r e v i o u s s e c t i o n h a s shown t h a t i n f a n t and c h i l d m o r t a l i t y r a t e s have been, and s t i l l a r e , d i f f e r e n t f o r t h e v a r i o u s socio- economic 6 : L c groups. They a r e h i g h r r among t h e scheduled c a s t e s t h a n among t h e C:hristians, h i g h e r among t h e c h i l d r r n o f t h e i l l i t e r a t e t h a n among t h e c h i l d r e n o f t h e educated; h i g h e r among t h e households w i t h no p r o t e c t e d t o i l e t f a c i l i t i e s , etc. What a r e t h e u n d e r l y i n g f a c t o r s of t h e s e d i f f e r e n t i a l s ? -W e h y p o t h e s i z e t h a t t h e m o r t a l i t y l e v e l among c k i l d r e n b o r n i n a household i s determined by: i. mothera h e a l t h , n u t r i t i o n a l l e v e l , etc ii. n u t r i t i o n r e c e i v e d by t h e c h i l d s i n c e b i r t h iii. medical a s s i s t a n c e r e c e i v e d by mother and c h i l d b e f o r e , a t , and a f t e r b i r t h iv. s a n i t a r y c o n d i t i o n s of t h e house and i t s l o c a l i t y . Each of t h e s e i s a f f e c t e d by t h e economic s t a t u s of t h e household, e d u c a t i o n a l a t t a i n m e n t o f t h e p a r e n t s and c u l t u r a l p r a c t i c e s p e r t a i n i n g t o c h i l d b e a r i n g and child rearing. The s a n i t a r y c o n d i t i o n s of t h e house w i l l be a f f e c t e d a l s o by t h e g e n e r a l l o c a t i o n of t h e household, and s a n i t a r y f a c i l i t i e s such a s w a t e r supply, t o i l e t f a c i l i t i s s , e t c . , i n t h e house. The p r e l i m i n a r y t a b u l a t i o n of t h e K e r a l a d a t a d o e s n o t g i v e measures of a l l f a c t o r s . The r r l e v a n t v a r i a b l e s i n t h e p r e l i m i n a r y t a b u l a t i o n s a r e : - mothere r d u c a t i o n : y e a r s of s c h o o l i n g - dand ownrd by t h e houaehold - t o i l e t f a c i l i t y I n t h e house - Water supply - - - .Caete i ' - Monthly household e x p e n d i t u r e - IL (v47) - Per c a p i t a household e x p e n d i t u r e C PCE Infant Mortality T h i s a n a l y s i s i s c o n f i n e d t o 8921 b i r t h s ( o u t of a t o t a l o f a b o u t 9400 r e p o r t e d i n t h e S u r v e y ) , which t o o k p l a c e a t l e a s t 1 2 months b e f o r e t h e survey d a t e . Thus, i t e x c l u d e s b i r t h s i n 1979 and 1980. T h i s i s done t o make s u r e t h a t a l l b i r t h s s h o u l d have t h e same (121nonth) e x p o s u r e p e r i o d . T h i s r e s t r i c t i o n , however, d o e s n o t s o l v e t h e problem r e l a t e d t o t h e choice of t h e b e s t dependent v a r i a b l e . T h e r e are a number of c h o i c e s : 1) number of d e a t h s ( i n f a n t ) p e r woman ii) p r o p o r t i o n of c h i l d r e n e v e r b o r n who d i e d i i i ) dummy v a r i a b l e 0 o r 1 d e f i n e d as 0, i f a b i r t h e n d s up i n a d e a t h d u r i n g t h e f i r s t 1 2 months and 1 i f i t s u r v i v e s t h e t h e f i r s t 1 2 months Other a l t e r n a t i v e s a r e p o s s i b l e , e s p e c i a l l y f u n c t i o n s o r transformations o f t h e above. I n t h e a n a l y s i s g i v e n below we have t r i e d ( i i ) p r o p o r t i o n o f i n f a n t d e a t h and ( i i i ) s u r v i v a l s t a t u s o f e a c h b i r t h . A p r o b i t a n a l y s i s o n dummy v a r i a b l e ( i i i ) ga7e t h e results i n T a b l e 10- The chance o f a c h i l d s u r v i v i n g i s s i g n i f i c a n t l y h i g h e r f o r r e c e n t b i r t h s t h a n f o r e a r l i e r b i r t h s ( p o s i t i v e a s s o c i a t i o n w i t h y e a r and month of b i r t h ) , f o r s i n g l e b i r t h s than f o r m u l t i p l e b i r t h s (negative a s s a c i a t i o n with twin- single s t a t u s ) f o r b i r t h s of higher o r d e r ( p o s i t i v e a s s o c i a t i o n with b i r t h o r d e r s e e - a l s o c h a r t 1) 1/, f o r c h i l d r e n of educated mothers t h a n f o r c h i l d r e n of i l l e t e r a t e mothers ( p o s i t i v e a s s o c i t i o n w i t h y e a r s of schooling of m o t h e r ) , f o r b i r t h t o h i g h e r c a s t e women ( p o s i t i v e a s s o c i a t i o n w i t h c a s t e ) and f o r b i r t h s i n - . households w i t h h i g h e r monthly e x p e n d i t u r e ( p o s i t i v e a s s o c i a t i o n w i t h monthly ; L - 1/ The r e l a t i o n s h i p between b i r t h o r d e r and i n f a n t m o r t a l i t y i s n o t l i n e a r . The IMR d e c r e a s e s w i t h b i r t h o r d e r when t h e b i r t h o r d e r i s s m a l l ( u p t o o r d e r 5) and t h e n i n c r e a s e s a t h i g h e r o r d e r b i r t h s .  household e x p e n d i t u r e ) . The a v a i l a b i l i t y o f p i p e w a t e r o r w e l l w a t e r does not make much d i f f e r e n c e a s f a r a s i n f a n t s u r v i v a l p r o b a b i l i t y i s concerned. The same i s t r u e o f t o i l e t f a c i l i t y and t h e amount o f l a n d owned by a house- hold. It was expected t h a t p r o t e c t e d w a t e r s u p p l y , p r o t e c t e d t o i l e t f a c i l i t y and l a r g e l a n d h o l d i n g s vould s i g n i f i c a n t l y reduce i n f a n t m o r t a l i t y . There I 1- V i s , however, no evidence f o r such r e l a t i o n s h i p s from t h e d a t a . i 1 Table 10: PROBIT ANALYSIS ON SURVIVAL STATUS DURING 1 $ ' FIRST YEAR OF EACH BIRTH Dependent V a r i a b l e : P r o b a b i l i t y of a Live B i r t h S u r v i v i n g The F i r s t 12 months Independent Variables Coefficient T- Statistics Mothers e d u c a t i o n ( y e a r s ) H.04778 6 0 Caste - 11 t0.1937 B i r t h S t a t u s ( s i n g l e o r twin) -0.8947 Year and month of b i r t h tO.CO1326 5.3 B i r t h Order - +1.4 Linear tO.1082 +3.6 Quadratic -0.0108 -3.3 Per C a p i t a e x p e n d i t u r e 0.1 Land - 0.2 I f Water Supply 21 - - -1.1 L T o t a l Household Expenditure* tO. 0004096 3.7 T o i l e t F a c i l i t y * 31 - -1.0 . *From a d i f f e r e n t r e g r e s s i o n from which t h e v a r i a b l e per c a p i t a hous~ehold e x p e n d i t u r e was excluded. I . - 11 Scheduled c a s t e s and t r i b e s = 0 ; a l l o t h e r s = 1 - 21 Pipe and w r f l = 1; a l l o t h e r s zero; A m o d i f i c a t i o n of t h i s i n which p i p e = 1; a l l o t h e r s z e r o d i d not a f f e c t t h e s t a t i s t i c a l s i g n i f i c a n c e . - 31 Flush and ESP S l a b = 1; a l l o t h e r s zero.  P r o b i t a n a l y s i s does n o t g i v e a good e s t ? a a t e of t h e tot-A, v a r i a n c e expla<ned by t h e r e g r e s s i o n . However, a v a i l a b l e i n f o r m a t i o n (e.g. l i k e l i h o o d 2 r a t i o R S t a t i s t i c i s only 0.030) i n d i c a t e s t h a t t h e independent v a r i a b l e s t o g e t h e r e x p l a i n only a v e r y s m a l l p e r c e n t of t h e t o t a l v a r i a n c e . The r e a l l y c r i t i c a l v a r i a b l e s which could e x p l a i n much of t h e v a r i a n c e of t h e p r o b a b i l i t y of s u r v i v a l a r e n o t included i n t h e a n a l y s i s . C . The above c o n c l u s i o n s a r e on t h e whole supported a l s o by a n ordi- n a v l e a s t s q u a r e s analy.:+.s of p r o p o r t i o n of i n f a n t d e a t h p e r woman (Table 11). Years of schooling of mother, h e r c a s t e and t h e average y e a r of occurance of h e r b i r t h s , a l l have s t a t i s t i c a l l y s i g n i f i c a n t l y n e g a t i v e r e l a t i o n s h i p with i n f a n t m o r t a l i t y ; l a n d , water supply and t o i l e t f a c i l i t y have no s i g n i f i c a n t relationship. In ~ h e s e r e s p e c t s , t h e c o c c l u s i o n s from p r o b i t a n a l y s i s and OLS a r e t h e same. However, t h e r e i s a d i f f e r e n c e between t h e two w i t h r e s p e c t t o t h e s i g n i f i c a n c e o f household expenditure. I n OLS, t o t a l householld e x - p e n d i t u r e d i d n o t show a s i g n i f i c a n t r e l a t i o n s h i p while t h e p r o b i t a n a l y s i s indicated a negative r e l a t i o n s h i p with i n f a n t mortality. Both approaches gave s i m i l a r r e l a t i o n s h i p - s t a t i s t i c a l l y insignificant relationship - with p e r c a p i t a household e x p e n d i t u r e , but t h e OLS e s t i m a t e i s only j u s t margi- n a l l y below t h e 95 p e r c e n t l e v e l o f s t a t i s t i c a l s i g n i f i c a n c e ( 9 4 . 9 % ) .  Table 11: ORDINARY LEAST SQUARES REGRESSION Dependent Variable: P r o p o r t i o n of C h i l d r e n Who Die i n t h e F i r s t 12 Months t Independent Variables 1 ) Average Year of b i r t h of a l l c h i l d r e n -0.06415 8.1 2) Years of Schooling (Mother) 3) Caste -0.08458 16.3 4) Land 5) Per C a p i t a Expenditure 6) Water Supply 7) T o i l e t F a c i l i t y 8 ) T o t a l Household Expenditure* - 1.0 * D i f f e r e n t r e g r e s s i o n i n which per c a p i t a e x p e n d i t u r e i s n o t included. Two o v e r a l l c o n c l u s i o n s emerge from t h e above a n a l y s i s : 1. Socio-economic f a c t o r s e x p l a i n o n l y a small p e r c e n t of t h e i n f a n t m o r t a l i t y d i f f e r e n t i a l s a t household l e v e l . 2. Economtc f a c t o r s such a s o ~ ~ r s h of i p l a n d , have a r e l a t i v e l y C s m a l l e r r o l e t o p l a y i n determining t h e p r o b a b i l i t y of i n f a n t d e a t h s i n a household than s o c i a l f a c t o r s such as mothers education o r her caste. - I f :socio-economic f a c t o r s cannot acco-t f o r much of t h e i n f a n t m o r t a l i t y d i f f e - 5 r e n t i a l s , t h e r e muat be o t h e r f a c t o r s y h i c h could. One such f a c t o r could be B h o s p i t a l u t i l i z a t i o n f o r pre- natal c a m , f o r confinement, and f o r post- natal c a r e of mother and c h i l d . But u n t i l d a t a a r e c o l l e c t e d and t e s t e d i t w i l l n o t be p o s s i b l e t o confirm t h i s .  The r e l a t i u n s h i p w i t h economic f a c t o r s v e r s e s s o c i a l f a c t o r s c o u l d a l s o be e x p l a i n e d i n terms o f h o s p i t a l u t i l i z a t i o n h y p o t h e s e i s . I n Kerala, g o v e m e n t h o s p i t , . l f a c i l i t i e s a r e f r e e t o most people. They a r e widely d i s t r i b u t e d o v e r t h e s t a t e and t h e t r a n s p o r t a t i o n net-work i s good and cheap. For example, o u t of t h e 150 sample v i l l a g e s ( p a n c h a y a t s ) i n t h e survey 137 had either L: government h o s p i t a l o r d i s p a n s a r y o r a p r i v a t e h o s p i t a l o r d i s p a n s a r y . T h e r e f o r e , t h e u t i l i z a t i o n of h o s p i t a l f a c i l i t i e s i s determined more by t h e i n d i v i d u a l demand f o r such s e r v i c e s t h a n by t h e i r supply o r l a c k o f money. Education i s a n i m p o r t a n t element i n t h e demand. Hence t h e s t a t i s t i c a l l y s i g n i f i c a n t r e l a t i o n s h i p between mothers s c h o o l i n g and i n f a n t m o r t a l i t y rate. I n t h e Kerala c o n t e x t , demand f o r and u t i l i z a t i o n o f h o s p i t a l f a c i l i - t i e s a r e a l s o determined by t h e d e g r e e of p e r s o n a l c o n t a c t w i t h h o s p i t a l o r dispensary s t a f f - doctors, n u r s e s , midwives, t e c h n i c i a n s e t c , . H i s t o r i c a l l y some communities ( S y r i a n C h r i s t i a n s , f o r example) were o v e r r e p r e s e n t e d among h o s p i t a l s t a f f t h a n o t h e r s (scheduled c a s t e , f o r example). Although t h i s imbalance h a s changed c o n s i d e r a b l y i t i s s t i l l p o s s i b l e t h a t h o s p i t a l s t a f f a r e d i s p r o p o r t i o n a t e l y d i s t r i b u t e d among t h e r e l i g i o u s and c a s t e groups. The s t a t i s t i c a l l y s i g n i f i c a n t a s s o c i a t i o n between c a s t e and i n f a n t m o r t a l i t y . I could be e x p l a i n e d by t h e d i f f z r e n t i a l u t i l i z a t i o n of h o s p i t a l f a c i l i t i e s , a r i s i n g from d i i f e r e & l personal contact with h o s p i t a l sys~em. - - L Neo-Natal and Child M o r t a l i t y - - P r o p t a n a l y s i s s i m i l a r t o t h a t done on i n f a n t d e a t h s *done I - neo- natal m o r t a l i t y (0 i f a b i r t h ends up i n a d e a t h d u r i n g t h e f i r s t month - for and 1 i f i t s u r v i v e s t h e f i r s t month) and c h i l d m o r t a l i t y (0 i f a b i r t h e n d s up i n a d e a t h d u r i n g 1 t o 4 y e a r s o f I t s l i f e and 1 i f It s u r v i v e s t h e f i r s t  f i v e years). The r e s u l t s a r e shown i n T a b l e 12. The r e s u l t s o f t h e ~ n a l y s i s of neo- natal - r t a l i t y i s v e r y s i m i l a r t o t h a t of i n f a n t m o r t a l i t y , b u t t h a t i of c h i l d mortal.. .y i s d i f f e r e n t . For neo- natal (and infar-,) m o r t a l i t y o r d e r 1 of b i r t h , s l & e o r twin s t a t u s of t h e b i r t h , c a s t e of t h e mother a r e statis- t i c a l l y s i g n i f i c a n t , w h i l e p e r c a p i t a e x p e n d i t u r e , l a n d , w a t e r supply, t o i l e t f a c i l i t y , e t c . , a r e not. On t h e o t h e r hand, f o r c h i l d m o r t a l i t y c a s t e , o r d e r of b i r t h , s i n g l e - t w i n s t a t u s , are n o t s i g n i f i c a n t , while economic f a c t o r s s u c h a s per c a p i t a e x p e n d i t u r e , ( h i g h e r e x p e n d i t u r e means h i g h e r s u r v i v a l proba- b i l i t y ) l a n d ( l a r g e r t h e s i z e of l a n d h o l d i n g , h i g h e r i s t h e s u n r i v a l proba- b i l i t y ) , water supply, t o i l e t f a c i l i t y , etc., a r e very important. T a b l e 12: PROBIT L W Y S I S OF NEO-NATAL AND CHILD SURVIVAL STATUS O F EACH BIRTH Independent Neo-Natal S u r v i v o u r s h i p ( f i r s t month) Child S u ~ i v o u r s h i p(1-4 Years) Variable Coefficient t- Statistic Cofficient t- Statistic Mother's e d u c a t i o n +. 052l9 6.2 +.03737 3-6 Cae t e +. 1316 2.1 - 1-7 B i r t h Order +. 02249 2.0 - -1.7 S i n g l e o r Twin B i r t h -.9123 -8.8 - -0.9 Year of B i r t h +.007802 3.0 i-. 002406 6-8 Per Capita ~ x ~ e n d i t u i e - - -1.6 +. 001564 2.1 Land -0.1 +. 0003671 2-4 Water Supply T o t a l Household - -1.1 +.I411 2-0 Expenditure* +.0002669 9.4 +. 0003343 2-3 T o i l e t Facilitytr - -r .O • +.I768 2.5 * From a d i f f e r e n t r e g r e s s i o n from which PCE w a s excluded. ANOMALY OF THE RELATIONSHIP BETWEEN PER CAPITA HOUSEHOLD ' EXPENDITURE AND INFANT MORTALITY RATE The p r e v i o u s s e c t i o n h a s i n d i c i t e d somewhat c o n f l i c t i n g reltation- I s h i p between i n f a n t m o r t a l i t y r a t e and pGr c a p i t a household e x p e n d i t u r e (PCE). P r o b i t a n a l y s i s showed no s t a t i s t i c a l l y s i g n i f i c a n t r e l a t i o n s h i p between t h e two ( t - -0.1); OLS a n a l y s i s of a l l b i r t h s i n d i c a t e d a m a r g i n a l l y s i g n i f i c a n t ( s i g n i f i c a n t a t 94.9% l e v e l ) p o s i t i v e r e l a t i o n s h i p ; and OLS of r e c e n t b i r t h s  (1975-79) g a v e a h i g h l y s i g n i f i c a n t p o s i t i v e a s s o c i a t i o n ( t = +2.5). 11 -- There -a no s u p p o r t f o r t h e e x p e c t e d n e g e t i v e a s s o c i a t i o n between PCE and LMR i n any o f t h e a n a l y s i s . T h i s i s n o t t h e f i r s t s t u d y which h a s come up with a non- negative r e l a t i o n s h i p between p e r c a p i t a e x p e n d i t u r e and i n f a n t m o r t a l i t y rate. I n f a c t , a p o s i t i v e r e l a t i o n s h i p seems t o be t h e geritsral p a t t e r n with Indian data. I n a recent artLcle N. K r i s h n a j i h a s brought attention to t h i s point rather dramatically. 21 - According t$ t h e n i n e t e e n t h round o f t h e NSS, t h e IMR was l o w e s t ( 3 3 p e r 1000) i n t h e l o w e s t e x p e n d i t u r e c l a s s and t h e h i g h e s t (293) i n t h e h i g h e s t e x p e n d i t u r e c l a s s . Such a " p e r v e r s e " r e l a t i o n s h i p between PCE and IMR i s r e p o r t e d t o have been observed i n a l l NSS rounds s i n c e 1953-54. One o f t h e e x p l a n a t i o n s g i v e n f o r t h i s p e c u l i a r r e l a t i o n s h i p i s t h e two-way c a u s a t i o n between PCE and m o r t a l i t y : income ( e x p e n d i t u r e ) a f f e c t i n g m o r t a l i t y and m o r t a l i t y a f f e c t i n g f a m i l y s i z e and t h u s a f f e c t i n g p e r c a p i t a in- come o r e x p e n d i t u r e . Do t h e Kerala d a t a s u p p o r t t h i s h y p o t h e s i s ? 1 This i s n o t p r e s e n t e d above. - 21 N. K r i s h n a j i , " P o v e r t y and Family S i z e " i n S o c i a l S c i e n t i s t S p e c i a l Number November 1980, pp 22-35. T a b l e I1 from t h i s a r t i c l e i s reproduced below: TABLE 11 DIFFERENTIAL MORTALITY RATES I N RURAL I N D I A (1964-65) .- = f Monthly P e r C a p i t a Expendit~re Death R a t e Infant Mortality Rate - ' - C (Rs a f 0-1 1 10.03 32.94. L 11-15 10.58 71-71. 15-2 1 13.38 122.29 21-28 16.06 152.37 2 8-4 3 17.88 153.13 43 and above 21.81 293.27' A l l groups 14.75 127 -29  T a b l e 1 3 g i v e s t h e d i s t r i b u t i o n o f households by t o t a l household e x p e n d i t u r e i n each PCE c l a s s . There a r e 178 households i n t h e lowest PCE c l a s s , i and a l l of them have a t o t a l e x p e n d i t u r e below Rs. 450 p e r month. There a r e 331 ' households i n t h e h i g h e s t PCE c l a s s (more t h a n Rs. 120). One of t h e s e households belongs t o t h e lowest. ( t o t a l ) e x p e n d i t u r e c l a s s ( l e s s t h a n Rs. 150). It became included i n t h e h i g h e s t PCt c l a s s simply because t h = r e was o n l y one member i n t h e household. 'ihus, t h e r i c h households a s measured by t h e t o t a l e x p e n d i t u r e a r e u s u a l l y n o t c l a s s i f i e d a s poor when they a r e c l a s s i f i e d on t h e b a s i s of p e r c a p i t a expenditure. On t h e o t h e r hand, some poor households (based on t o t a l expendi- t u r e ) sometimes g e t c l a s s i f i e d a s r i c h when t h e c r i t e r i o n i s changed from t o t a l t o per c a p i t a expenditure. Thus t h e " m i s c l a s s i f i c a t i o n " i s n o t symmetric: tkc chance of "poor" becoming " r i c h " i s g r e a t e r t h a n a " r i c h " becoming "poor". Consequently t h e IMR o f t h e " r i c h " (PCE b a s i s ) i s o v e r e s t i m a t e d . T a b l e 13: DISTRIBUTION OF HOUSEHOLDS BY TOTAL HOUSEHOLD WENDITURE I N EACH PCE CLASS PCE - Total Rs 30-49 50-59 60-79 80-11 9 1201- Total Expenditure <30 <I50 25.8 3.7 1.3 1.3 0.2 0.3 3.2 1500 -- -- -- --- 0.8 15.1 2 .O 100 100 100 100 100 100 100 Number of Households 178 678 454 548 490 331 267 9  - 20 - A more r r v i d c o n f i r m a t i o n of t h i s s h i f t i s provided i n Tab1.e 14 where t h e poor households v h i c h became r i c h ( p 3 R) due t o t h e change i n a t ti?e bottom of the t a b l e ) i s compared w i t h r i c h criterion (see f ~ o t n o t e households which became poor ( R P ) I n t h e f i r s t c a t e g o r y (P+ R.) t h e r e i s no household w i t h more t h a n 7 persons and t h e average s i z e of t h e house- hold was o n l y 4.25. I n t h e second category (R+ P) t h e r e i s n o t e v e r one household w i t h l e s s than 7 persons. The average s i z e of t h e household i s 11.43 persons. T h i s p e r f e c t eepar'tion is q u i t e accidental, but the l a r g e d i f f e r e u c e between of t h e i r averages (by a s much a s 7 persons per household i n t h i s c a s e ) I s ?ot. Tthe "poor" f a m i l i e s became " r i c h " mainly because of t h e small s i z e cjf t h e i r f a m i l i e s and t h e "ric'l" became "poor" because of t h e v e r y l a r g e s i z e of t h e household. Table 14: DISTRIBUTION OF SELECTED HOUSEHOLDS BY FAMILY SIZE, CHILDREN EVER BORN AND CHILDREN DEAD OF HOUSEHOLD Household S i z e No. Of children Children Died Households Ever Born (P T r <R-+ P) (P+ R) ( R J P) (HR) (RJ P) 0 - - 53 18 365 135 1 4 - 73 26 93 32 2 42 - 121 43 49 9 4 85 - 117 17 14 7 4 160 - 78 18 6 1 5 157 - 34 12 4 - € 68 - 32 7 - - 7 11 - - 12 13 - - - - , 8 15 6 i10 9 - 41 3 12 - - 10 - 37 1 2 - - 11 - 13 - 3 - - - 12 - 25 - '7 - - - - - 6 13 11 1 1 - .3 14 15 - - 11 22 - - - - - - - - - - * A 16 - .. 5 - - - - Q 0 Total 531 184 ' 5 31 184 5 31 184 Average 4.25 11.43 2.87 3.84 0.52 -- 0.41 (P-+ R) a Households i n which t o t a l e x p e n d i t u r e i s low ( l e s s t h a n Re. 450). - b u t per c a p i t a e x p e n d i t u r e i s h i g h (more t h a n R s . 60 p e r month). (R+ P) = Households i n v h i c h r o t a 1 e x p e n d i t u r e i s high (more than R s . 450). b u t per c a p i t a e x p a n d i t u r e i s :ow ( l e s s than R Y . 6 0 p e r month.  The asymmetry o f t h e s h i f t i s q u i t e e v i d e n t from t h i s t a b l e a l s o . While 184 r i c h households became "poor" a s many a s 531 h o u s e h o l d s moved i n t h e opposite direction. Thus, t h e c r i t e r i o n o f PCE t e n d s t o i n c r e a s e t h e m o r t a l i t y l e v e l of t h e r i c h d e f i n z d on t h e b a s i s of t o t a l e x p e n d i t u r e . Is t h e anorcalous r e l a t i o n between PCE and ZMR d u e t o h i g h e r m o r t a l i t y t h e poor and i t s e f f e c t on PCE? To answer t h i s q u e s t i o n a n a3jrist.ed p e r c a p i t a household e x p e n d i t u r e (APCE) was c a l c u l a t e d f o r e a c h household as a r a t i o of t o t a l e x p e n d i t u r e t o t h e e x p e c t e d household s i z e i f none of t h e c h i l d - r e n had d i e d ; t h a t i s , T o t a l Monthly Household E x p e n d i t u r e APCE = Household S i z e f D e a t h s Among Ever- Born C h i l d r e n APCE i s t h u s i n d e p n n A e n t of t h e number of d e a t h s among t h e c h i l d r e n . Using APCE, r e g r e s s i o n c o e f f i c i e n t s were re- estimated by che OLS and P r o b i t a n a l y s i s . The OLS g a v e a s t a t s t i c a l l y s i g n i f i c a n t n e g a t i v e r e l a t i o n s h i p (B = 0.5%) P R ~ - 11 between p r o p o r t i o n of c h i l d r e n who d i e d and APCE. - -0.080; F -1 11.0; k 1/ j 1 1 - I t may b e argued t h a t t h e n e g a t i v e r e l a t i o t t s h i p i s i n e v i t a b l e a s d e a t h s occur i n t h e denominator of t h e independent v a r i a b l e : Expenditure APCE = H.H. 'size + D ( A l l deaths) 1. and t h e numerator o f t h e dependent v a r i a b l e - - '9 i D ' ( i n f a n t d e a t h s which i s 55% of D ) - C -T ( a i l d r e n ever- born) - However, H.H@size i s n e t o f a l l d e a t h s and t h e r e f o r e when D i s added t h e denominator df APCE becomes i n d e p e r d e n t of D. !  - The p r o b i t a n a l y s i s a l s o gave a s t a t i s t i c a l l y s i g n i f i c a n t : n e g a t i v e - r e l a t i o n s h i p between APCE and i n f a n t m o r t a l i t y ( t * -7.9). Thus, i n s i g n i f i c a n t r e l a t i o n s h i p between PCE and i n f a n t m o r t a l i t y became s i g n i f i c a n t once t h e PCE i s adjusced co make i t independent o f t h e d e a t h s I n t h e household. Thus, t h e Kerala d a t a s u p p o r t t h e c i r c u l a r c a u s a t i o n .jpcjtttesis. The observed p o s i t i v e o r n o n - s i g n i f i c a n t r e l a t i o n s h i p between PCE and IMR i s due t o t h e i n v e r s e r e l a t i o n s h i p between income and m o r t a l i t y , and che i n v e r s e r e l a t i o n s h i p between m o r t a l i t y and household s i z e . These r e s u l t s i n a d i r e c t r e l a t i o n s h i p between m o r t a l i t y and PCE. P e r c a p i t a household e x p e n d i t u r e does n o t appear t o be a good measure of t h e economic s t a t u s of a household f o r use i n demographic a n a l y s i s , particularly i n mortality analysis.  POPULATION & HUMA.N RESOURCES DIVISION DISCUSSION PAPERS [ A * by t h e number i n d i c a t e s t h e paper i s Bank- confidential o r otherwise r e s t r i c t e d . ] 81-1 Oey A. Meesook, "Demographic C h a r a c t e r i s t i c s of I n d i v i d u a l s and t h e Measurement of Lifetime Incorne". February 1981. 81-2 Susan 8. Cochrane, "The Economics of F e r t i l i t y w i t h Examples from Asia". February 1981. 81-3 Rashid Faruqee, "SocLd~ ;:,qrastructure and S e r v i c e s i n Zimbabwe". February 1981. 1 81-4* Richard Sabot, A. Berr,, A. Hazlewood, J. Knight, J. Armitaga and i M. B o i s s i e r e , "Cognitive S k i l l s : Their Determinants and P I n f l u e n c e on Earnings i n Tvo Poor Urban Economies." February 1981. i Dean T. Jamison, Sarbara ~ e a r i e ,Stephen Heyncman, and Klaus Galda 81-5 "Improving Elementary Mathematics Education i n Nicaragua: An I Experimen'al Study of t h e Impact of Textbooks and Radio on Achievement". March 1981. i 5 B k- 81-6 Rashid Faruqee, "Analyzing t h e Impact of Health Services: and Other Expe-iences". March 1981. Narangwal F 81-7 J. B. Knight and R . 8. Sabot, "Labor Market Discrimination i n a Poor Urban Economy". March 1981. 81-8 Oey A. Meesook, " I n t e r r e l a t i o n s h i p s between Demographic F a c t o r s and Income D i s t r i b u t i o n : Problems of Measurement, & s c r i p t i o n and I n t e r p r e t a t i o n " . April 1981. 81-9 Susan 8 . Cochrane, Nirmala J o s h i and Kalpana Nandwani, " F e r t i l i t y A t t i t u d e s and Behavior i n t h e Nepal Terai" . A p r i l 1981. 81-10 J . B . Knight and Richard Sabot, "The Role of t h e Finn i n Wage Determination: An African Case Study". A p r i l 1981. r L 81-11 J. B. Knight and ~ i c $ r d Sabot, "The Returns t o Education: I n c r e a s i n g w i t h Experience o r Decreasing w i t h Expansion?". March 1981. 81-12 J . B . Knight and Richard Sabot, "From Migrants t o P r o k t a r i a n s : Employment Experience, Mobility and Wages i n Tanzanm". March 1981. - 81-13 A.-Berry and Richard Sabot, "Unemployment and Economfi k v e l o p r ~ e n t " . 81-14 &ti1 1981. I r- Rashid Faruqee and Ethna Johnson, "Health, N u t r i t i o n and Family Plannfng: A Survey of Experiments and S p e c i a l P r o j e c t s i n India" . A p r i l 1981. 81-15 Francois O r i v e l and Dean T. Jamison, "The Cost-Effectiven~ess of Distance Teaching P r o j e c t s " . June 1981 81-16 Richard S a b o t , "Labor Force Growth, Employment and E a r n i n g s i n Egypt: 1966-1968". May 1981. 81-17 K.C. Z a c h a r i a h , "Anomaly of t h e F e r t i l i t y D e c l i n e i n Kerala: Social Development, A g r a r i a n Reforms, o r t h e Family Planning Program". May 1981. 81-18 Richard S a b o t , A. Berry, A. Hazlewood, J. Knight, P. C o l l i e r , J. Armitage, M. B o i s s i e r e , " Education Expansion and Labor Market Adjustment i n Kenya and Tanzania - A Background Paper". May 1981. 81-19 Nancy B i r d s a l l and Oey Meesook, " Child s c h o o l i n g , Number of C h i l d r e n and I n t e r g e n e r a t i o n a l Transmission of I n e q u a l i t y : A S i m u l a t i o n " . May 1981. 81-20 F r a n c o i s O r i v e l , "The Impact o f A g r i c u l t u r a l E x t e n s i o n S e r v i c e s : A Review of t h e L i t e r a t u r e " . J u l y 1981. Also a v a i l a b l e i n F r e n c h a s "L'impact d e s S e r v i c e s d e V u l g a r i s a t i o n A g r i c o l e : Revue d e l a Littgrature". 81-21 Nancy B i r d s a l l and M. Louise Fox, "Why Males Earn More: L o c a t i o n , J o b P r e f e r e n c e s and J o b D i s c r i m i n a t i o n Among B r a z i l i a n S c h o o l t e a c h e r s " . May 1981. 81-22 A l t h e a H i l i , "The Demographic S i t u t a t i o n i n Sub-Saharan A f r i c a : A D i s c u s s i o n Paper" . May 1981. 81-23* R . S a b o t , 5. B e r r y , A. Hazlewood, J. Knight, J. Armitage, M. B o i s s i e r e "Does t h e Expansion of Education Compress t h e S t r u c t u r e of Wages and Reduce t h e I n e q u a l i t y o f Pay? A P r e l i m i n a r y Analysis" . J u l y 1981. 81-24* Nancy B i r d s a l l and Dean T. Jamison. "Income and Other F a c t o z s I n f l u e n c i n g F e r t i l i t y aad M o r t a l i t y i n China". October 1981. 81-25* Nancy B i r d s a l l , Sulekha P a t e 1 and K. C. Z a c h a r i a h , " A l t e r n a t i v e P r o j e c t i o n s o f t h e Chinese Population" . June 1981. 51-26* Dean T. Jamison, T.J. Ho, and F.L. Trowbridge. "Food A v a i l a b i l i t y ' and t h e N u t r i t i o n a l S t a t u s o f C h i l d r e n i n ~ h l n a " . October 1981. 81-27* Dean T. Jamison. " Child M a l n u t r i t i o n and School R e t a r d a t i o n i n China". September 1981. 81-28 Deborah Lhamon Macmillan. "Language P o l i c i e s f o r A f r i c a n Primary Education: Summary of t h e Anglophone Research L i t e r a t u r e . " J u l y 1981. E 81-29 Tania Thevenin. "Les I m p l i c a t i o n s Pedagogiqoes d e s P o l i r i q u e s d e l a n g u e s d a n s l'enseignement e n Afrique: Une revue d e l a l i t t e r a t u r e Francophone". June 1981. Also a v a i l a b l e i n E n g l i s h a s " P e d a g o g i c a l I m p l i c a t i o n s o f Language P o l i c y i n A f r i c a n Schools: A Review o f t h e Francophone L i t e r a t u r e " . 81-30 Vicente Paqueo. "A Household Production Model of School Enrollment: A P r o b i t A n a l y s i s 02 t h e 1978 B i c o l Multipurpose Survey Data". June 1981 Bryan L. Boulier and Vicente B. ~ a i u e o ."On t h e Theory and Measurements of t h e Determinants of M o r t a l i t y " . June 1981 Repnaldo M a r t o r e l l . " N u t r i t i o n and Health S t a t u s I n d i c a t o r s ~ : Suggeotions f o r Surveys of t h e Standard of Living : A Developing Countries" . June 1981. R. Sabot, A. Berry, A. EIazelvood, J. Knight, J. Armitage, and M. B o i s s i e r e . " C o r r e l a t e s of Educational Attainment i n Tanzania". J u l y 1981. Susan H. Cochrane. "The Determinants of F e r t i l i t y and Chf1.d . S u r v i v a l i n t h e Nepal Terai" . J u l y 1981. Joanne L e s l i e , B.G. Baidya, and K. Nandwani. " Prevalence and C o r r e l a t e s of Childhood M a l n u t r i t i o n i n t h e T e r a i Region of Nepal". J u l y 1981. R. Mansell Prothero. " P e r s p e c t i v e s on Population M o b i l i t y An West Africa" . August 1981. Timothy King. " Population Grovth, I n t e r n a t i o n a l Resource T r a n s f e r s , and I n t e r n a t i o n a l Migration". August 1981 Timothy King. "Immigration from Developing Countries: Some P h i l o s o p h i c a l Issuee". August 1981. R. Sabot and J. Knight. "Why Wages D i f f e r : Earnings Functions i u a Poor Urban Economy". August 1981. Joao B a t i s t a d e Araujo e O l i v e i r a and Francois O r i v e l . " In- Service Teacher T r a i n i n g System: Logos 1 1 i n Brazil" . August 1981. R1 Sabot, A. Berry, A. Hazlewood, J. Knight, J. Armitage and M. B o i s s i e r e . " C o r r e l a t e s of Educational Attainment i n Kenya". August 1981. P e t e r Pallon. "Incomes, Poverty and Income DAstribution i n Rural Botswana: A S y n t h e s i s of Evidence Based on t h e Rurai Income D i s t r i b u t i o n Survey." September 1981. - Barbara ~ a t a n a b eand Eva Mueller. "A Poverty P r o f i l e f o r ~ t k a l Botswana." October 1981. Eva Mueller. "The Value and A l l o c a t i o n of Time i n Rural Botswana." November 1981. 81-45 Robert E.B. Lucas. "The D i s t r i b u t i o n and E f f i c i e n c y of Crop Production i n T r i b a l Areas of Botswana." September 1981. 81-46 Robert E.B. Lucas. "The D i s t r i b u t i o n of Wages and Employment i n Rural Botswana." September 1981. Dov Chernichovsky. "Socioeconomic and Demographic Aspects of School Enrollment and Attendance i n Rural Botswana." October 1981. Dov Chernichovsky. "Socioeconomic C o r r e l a t e s 01F e r t i l i t y Behavior i n Rural Botsvana." October 1981. S h e r r i Kossoudji and Eva Mueller. "The Economic and Demographic S t a t u s of Female Headed Households i n Botswana." October 1981. F r a n c o i s Orivel. "La T616vision S c o l a i r e du S6n6gal: Evaluation Economique e t Perspectives." Aout 1981. (Summary a v a i l a . b l e i n English. ) H i l l a r y P e r r a t o n , Dean T. Jamison and Francois Orivel. "Mass Media f o r A g r i c u l t u r a l Extension i n Malawi". September 1981 Thomas W. Merrick. "The Impact of Access t o Piped Water on I n f a n t M o r t a l i t y i n Urban B r a z i l , 1970 t o 1976." August 1981. N. Krishnan Narnboodiri. "Determinants of F e r t i l i t y i n S r i Lanka." September 1981. N. Krishnan Namboodiri. "Age a t Marriage i n S z i Lanka." October 1981. R. Sabot, A. Berry, A. Hazlewood, J. Knight, J. Armitage, M. B o i s s i e r e . "The S t r u c t u r e of Wsges i n Kenya and Tanzania: What Role Has Pay P o l i c y Played?" October 1981. ."Wage Sabot, A. Berry, A. h z l e w o o d , J. Knight, J. Annftage, M. B o i s s i e r e . Dynamics i n Tanzania and Kenya: Policy Simulations." October 1981. . P Dov Chernichovsky and Oey A. Meesook. "Female Labor Force P a r t i c i p a t i o n i n Indonesia.", October 1981. i Dov ~ h e r n i c h o v s & and Oey A. Meesook. "Poverty i n Indoensia: A P r o f i l e . " Novgmber 1981. * Susan H . ~ o c h r a anda Kalpana Nandwani. "The Determinants of F e r t i l i t y i n 22 V i l l a g e s cf Northern Thailand." December 1981. Forthcoming 81-61 Susan H. Cochrane and Dean T. Jamison. "The Determinants and Consequences of Educational Achievement in the Rural Chiang Mai Valley." December 1961.  POPULATION 6 HUMAN RESOURCES DIYISION DISCUSSION PAPERS [A *by the number indicates the paper i s Bank-confidential or otherwise restricted] 82-1 Hilary Perraton, "Mass Media, l a s i c Education and Agricultural . ~ x t e n e i o n " January 1982 82-2* Trends and Determinants of Infant and Child Mortality i n Kerala. January 1982.