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  • S. K. Mishra (a1), Bali Ram (a2) (a3), Abhishek Singh (a4) and Awdhesh Yadav (a5)


Using data from India’s National Family Health Survey, 2005–06 (NFHS-3), this article examines the patterns of relationship between birth order and infant mortality. The analysis controls for a number of variables, including mother’s characteristics such as age at the time of survey, current place of residence (urban/rural), years of schooling, religion, caste, and child’s sex and birth weight. A modest J-shaped relationship between birth order of children and their risk of dying in the neonatal period is found, suggesting that although both first- and last-born children are at a significantly greater risk of dying compared with those in the middle, last-borns (i.e. fourth and higher order births) are at the worst risk. However, in the post-neonatal period first-borns are not as vulnerable, but the risk increases steadily with the addition of successive births and last-borns are at much greater risk, even worse than those in the neonatal period. Although the strength of relationship between birth order and mortality is attenuated after the potential confounders are taken into account, the relationship between the two variables remains curvilinear in the neonatal period and direct in the post-neonatal period. There are marked differences in these patterns by the child’s sex. While female children are less prone to the risk of dying in the neonatal period in comparison with male children, the converse is true in the post-neonatal period. Female children not only run higher risks of dying in the post-neonatal period, but also become progressively more vulnerable with an increase in birth order.


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Altindag, O. (2016) Son preference, fertility decline, and the nonmissing girls of Turkey. Demography 53, 541566.
Astolfi, P., Ulizzi, L. & Zonta, L. A. (2000) Natural selection and reproductive behaviour in Italy 1930–1993. Human Biology 72, 349357.
Astolfi, P. & Zonta, L. A. (1999) Risks of preterm delivery and association with maternal age, birth order and fetal gender. Human Reproduction 14, 28912894.
Ayeni, O. & Oduntan, S. O. (1978) The effects of sex, birthweight, birth order and maternal age in infant mortality in a Nigerian community. Annals of Human Biology 5, 353358.
Barclay, K. J. (2014) The Long-term Impact of Birth Order on Health and Educational Attainment. Stockholm University, Stockholm.
Barclay, K. J. & Kolk, M. (2015) Birth order and mortality: a population based cohort study. Demography 52, 613639.
Basu, A. M. & Stephenson, R. (2005) Low level of maternal education and the proximate determinants of childhood mortality: a little learning is not a dangerous thing. Social Science & Medicine 60, 20112023.
Bhalotra, S., Valente, C. & Van Soest, A. (2009) The Puzzle of Muslim Advantage in Child Survival in India. Discussion Paper No. 4009, Institute for the Study of Labor (IZA), Bonn, Germany.
Bicego, G. T. & Boerma, J. T. (1993) Maternal education and child survival: a comparative study of survey data from 17 countries. Social Science & Medicine 36, 1207–1027.
Black, R. E., Morris, S. S. & Bryce, J. (2003) Why and where are 10 million children dying every year? Lancet 361, 22262234.
Black, S. E, Devereux, P. J. & Salvanes, K. G. (2005) The more the merrier? The effect of family size and birth order on children’s education. Quarterly Journal of Economics 120, 669700.
Blake, J. (1981) Family size and the quality of children. Demography 18, 421442.
Brenøe, A. A. & Molitor, R. (2015) Birth Order and Health of Newborns: What Can We Learn from Danish Registry Data? CINCH – Health Economics Research Center Edmund-Körner-Platz, Essen, Germany.
Buckles, K. C. & Kolka, S. (2014) Parental investment, breastfeeding, and birth order. Social Science & Medicine 118, 6670.
Cabrera, R. (1980) The influence of maternal age, birth order and socioeconomic status on infant mortality in Chile. American Journal of Public Health 70, 174177.
Caldwell, J. (1979) Education as a factor in mortality decline. Population Studies 33, 395413.
Choe, M. K., Ho, H. & Wang, F. (1995) Effects of gender, birth order, and other correlates on childhood mortality in China. Social Biology 42, 5064.
Cleland, J. G. & Van Ginneken, J. K. (1988) Maternal education and child survival in developing countries: the search for pathways of influence. Social Science & Medicine 27, 13571368.
Cote, K., Blanchard, R. & Lalumiere, M. L. (2003) The influence of birth order on birth weight: does the sex of the preceding sibling matter? Journal of Biosocial Science 35, 455462.
Croll, E. J. (2002) Fertility decline, family size and female discrimination: a study of reproductive management in East and South Asia. Asia-Pacific Population Journal 7, 1138.
Das Gupta, M. (1987) Selective discrimination against female children in rural Punjab, India. Population and Development Review 13, 77100.
Das Gupta, M. & Bhat, P. N. M. (1997) Fertility decline and increased manifestation of sex bias in India. Population Studies 51, 307315.
Das Gupta, M., Zhenghua, J., Bobua, L., Zbenming, X., Chung, W. & Hwa-Ok, B. (2003) Why is son preference so persistent in East and South Asia? A cross-country study of China, India and the Republic of Korea. Journal of Development Studies 40, 153187.
Dowding, V. M. (1981) New assessment of the effects of birth order and socioeconomic status on birth weight. British Medical Journal 282, 683686.
Elliott, B. A. (1992) Birth order and health: major issues. Social Science & Medicine 35, 443452.
Fessler, D. M. T., Navarrete, C. D., Hopkins, W. & Izard, M. K. (2005) Examining the terminal investment hypothesis in humans and chimpanzees: associations among maternal age, parity, and birth. American Journal of Physical Anthropology 127, 95104.
Finley, J. E., Ozaltin, E. & Canning, D. (2011) The association of maternal age with infant mortality, child anthropometric failure, diarrhoea and anaemia for first births: evidence from 55 low- and middle-income countries. British Medical Journal Open 2011(1), e000226.
Gavrielov-Yusim, N., Battat, E., Neumann, L., Friger, M. & Balicer, R. D. (2012) Birth order and private voluntary immunization – a study of 110,902 children. Vaccine 30, 442447.
Geruso, M. & Spears, D. (2014) Sanitation and health externalities: resolving the Muslim mortality paradox. Paper presented at the Annual Meeting of the Population Association of America, Boston, MA, USA, 1st–3rd May 2014.
Govindasamy, P. & Ramesh, B. M. (1997) Maternal Education and the Utilization of Maternal and Child Health Services in India. National Family Health Survey Subject Reports No. 5. International Institute for Population Sciences, Mumbai, India, and Macro International Inc., Calverton, MD, USA.
Gribble, J. N. (1993) Birth intervals, gestational age, and low birth weight: are the relationships confounded? Population Studies 47, 133146.
Guillot, M. & Allendorf, K. (2010) Hindu–Muslim differentials in child mortality in India. Genus 66, 4368.
Haaga, J. G. (1989) Mechanisms for the association of maternal age, parity, and birth spacing with infant health. In Parnell, A. M. (ed.) Contraceptive Use and Controlled Fertility: Health Issues for Women and Children Background Papers. National Academy Press, Washington, DC.
Hanushek, E. (1992) The trade-off between child quantity and quality. Journal of Political Economy 100, 84117.
Holman, R. C., Shay, D. K., Curns, A. T., Lingappa, J. M. & Anderson, L. J. (2003) Risk factors for bronchiolitis-associated deaths among infants in the United States. Pediatric Infectious Disease Journal 22, 483489.
Horton, S. (1988) Birth order and child nutritional status: evidence from the Philippines. Economic Development and Cultural Change 36, 341344.
Hotz, V. J. & Pantano, J. (2015) Strategic parenting, birth order and school performance. Journal of Population Economics 28, 911936.
IIPS & ORC Macro (2007) National Family Health Survey (NFHS-3), India, 2005–06. ORC Macro, Calverton, MD, USA and International Institute for Population Sciences, Mumbai.
Kaplan, B. A., Mascie-Taylor, C. G. N. & Boldsen, J. (1992) Birth order and health status in a British national sample. Journal of Biosocial Science 24, 2533.
Kembo, J. & Van Ginneken, J. K. (2009) Determinants of infant and child mortality in Zimbabwe: results of multivariate hazards analysis. Demographic Research 21, 367384.
Kramer, M. S. (1987) Determinants of low birth weight: methodological assessment and meta-analysis. Bulletin of the World Health Organization 65, 663737.
Lahiri, S., Hazra, A. & Singh, A. (2011) Sex differentials in childhood mortality in Punjab and Haryana – are they reality? Journal of Population Studies 43, 7198.
Lawn, J. E., Zupan, C. S. & Lancet Neonatal Survival Steering Team (2005) 4 million neonatal deaths: when? Where? Why? Lancet 365, 891900.
Li, L. & Wu, X. (2011) Gender of children, bargaining power, and intrahousehold resource allocation in China. Journal of Human Resources 46, 205316.
McCormick, M. C. (1985) The contribution of low birth weight to infant mortality and childhood morbidity. New England Journal of Medicine 312, 8290.
Matthews, T. J. & MacDorman, M. (2013) Infant Mortality Statistics from the 2009 Period Linked Birth/Infant Death Data Set. National Vital Statistics Reports No. 61 (8). National Centre for Health Statistics, Hyattsville, MD, USA.
Miller, J. E. (1994) Birth order, interpregnancy interval and birth outcomes among Filipino infants. Journal of Biosocial Science 26, 243259.
Modin, B. (2002) Birth order and mortality: a life-long follow-up of 14,200 boys and girls born in the early 20th century Sweden. Social Science & Medicine 54, 10511064.
Pandey, A., Choe, M. K., Luther, N. Y., Sahu, D. & Chand, J. (1998) Infant and child mortality in India. National Family Health Survey Subject Reports No. 11. International Institute for Population Sciences Mumbai, India and East–West Center Program on Population Honolulu, Hawaii, USA.
Parish, W. L. & Willis, R. J. (1993) Daughters, education, and family budgets: Taiwan experiences. Journal of Human Resources 28, 863898.
Penn, D. J. & Smith, K. R. (2007) Differential fitness costs of reproduction between the sexes. Proceedings of the National Academy of Sciences of the USA 104, 553558.
Price, J. (2008) Parental quality time: does birth order matter? Journal of Human Resources 43, 240265.
Puffer, R. R. & Serrano, C. V. (1975) Birthweight, Maternal Age and Birth Order: Three Important Determinants of Infant Mortality. Pan American Health Organization, World Health Organization, Washington, DC.
Ram, B. (2012) Fertility decline and family change in India: a demographic perspective. Journal of Contemporary Family Studies 42, 1140.
Ram, B., Singh, A. & Yadav, A. (2016) The persistent caste divide in India’s infant mortality: a study of Dalits (ex-untouchables), Adivasis (indigenous peoples), other backward classes, and forward castes. Canadian Studies in Population 43, 249263.
Ram, U., Jha, P., Ram, F., Kumar, K., Awasthi, S., Seth, A. et al. (2013) Neonatal, 1–59 month, and under-5 mortality in 597 Indian districts, 2001 to 2012: estimates from national demographic and mortality surveys. Lancet 1, e219e226.
Rao, R. S., Caleb, L., Khan, M. E. & Townsend, J. W. (2001) Safer maternity in rural Uttar Pradesh: do primary health services contribute? Health Policy and Planning 16, 256263.
Ren, X. T. (1995) Sex differences in infant and child mortality in three provinces in China. Social Science & Medicine 40, 12591269.
Riordan, D. V., Morris, C., Hattie, J. & Stark, C. (2011) Family size and perinatal circumstances, as mental health risk factors in a Scottish birth cohort. Social Psychiatry and Psychiatric Epidemiology 47, 975e983.
Samuelsen, S. O., Magnus, P. & Bakketeig, L. (1998) Birth weight and mortality in childhood in Norway. American Journal of Epidemiology 148, 983991.
Sawyer, C. C. (2012) Child mortality estimation: estimating sex differences in childhood mortality since the 1970s. PLoS Medicine 9(8), e1001287.
Schaffer, S. J. & Szilagyi, P. G. (1995) Immunization and birth order. Archive of Paediatrics and Adolescent Medicine 149, 792797.
Seidman, D. S., Ever-Hadani, P., Stevenson, D. K., Slater, P. E., Harlap, S. & Gale, R. (1988) Birth order and birth weight reexamined. Obstetrics and Gynaecology 72, 158162.
Shoham-Yakubovich, I. & Barell, V. (1988) Maternal education as a modifier of the association between low birthweight and infant mortality. International Journal of Epidemiology 17, 370377.
Siervo, M., Horta, B., Stephen, B., Victoria, C. & Wells, J. (2010) First-borns carry a high metabolic risk in early adulthood: evidence from a prospective cohort study. PLoS One 5(11), doi: 10.1371éjournal.pone.0013907.
Singh, R. & Tripathi, V. (2013) Maternal factors contributing to under-five mortality at birth order 1 to 5 in India: a comprehensive multivariate study. SpringerPlus 2, 284, doi: 10.1186/2193-1801-2-284.
Sonneveldt, E. W., Plosky, D. & Stover, J. (2013) Linking high parity and maternal and child mortality: what is the impact of lower health services coverage among higher order births? BMC Public Health 13 (Supplement 3), doi: 10.1186/1471-2458-13-S3-S7.
Strachan, D. P. (1989) Hay fever, hygiene, and household size. British Medical Journal 299, 12591260.
Sulloway, F. J. (1996) Born to Rebel: Birth Order, Family Dynamics, and Creative Lives. Pantheon Books, New York.
Swamy, G., Edwards, S., Gelfand, A., James, S. A. & Miranda, M. L. (2012) Maternal age, birth order, and race: differential effects on birthweight. Journal of Epidemiology and Community Health 66, 136142.
UNICEF (2014) Levels and Trends in Child Mortality. United Nations Children’s Fund, New York.
UNICEF & WHO (2004) Low Birthweight: Country, Regional and Global Estimates. United Nations Children’s Fund, UNICEF, New York.
Wilcox, A. J. & Russell, I. T. (1983) Birthweight and perinatal mortality: II. On weight-specific mortality. International Journal of Epidemiology 12, 319325.
Wong, S. S. (1990) Birth order and birth weight of Saudi newborns. Perspectives on Public Health 110, 9697.
Zajonc, R. B. & Markus, G. B. (1975) Birth order and intellectual development. Psychological Review 82, 7488.


  • S. K. Mishra (a1), Bali Ram (a2) (a3), Abhishek Singh (a4) and Awdhesh Yadav (a5)


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