title: Residual confounding explains the association between high parity and child mortality.
abstract: BACKGROUND
  This study used data from recent Demographic and Health Surveys (DHS) to examine the impact of high parity on under-five and neonatal mortality. The analyses used various techniques to attempt eliminating selection issues, including stratification of analyses by mothers' completed fertility.
  
  
  METHODS
  We analyzed DHS datasets from 47 low- and middle-income countries. We only used data from women who were age 35 or older at the time of survey to have a measure of their completed fertility. We ran log-binominal regression by country to calculate relative risk between parity and both under-five and neonatal mortality, controlled for wealth quintile, maternal education, urban versus rural residence, maternal age at first birth, calendar year (to control for possible time trends), and birth interval. We then controlled for maternal background characteristics even further by using mothers' completed fertility as a proxy measure.
  
  
  RESULTS
  We found a statistically significant association between high parity and child mortality. However, this association is most likely not physiological, and can be largely attributed to the difference in background characteristics of mothers who complete reproduction with high fertility versus low fertility. Children of high completed fertility mothers have statistically significantly increased risk of death compared to children of low completed fertility mothers at every birth order, even after controlling for available confounders (i.e. among children of birth order 1, adjusted RR of under-five mortality 1.58, 95% CI: 1.42, 1.76). There appears to be residual confounders that put children of high completed fertility mothers at higher risk, regardless of birth order. When we examined the association between parity and under-five mortality among mothers with high completed fertility, it remained statistically significant, but negligible in magnitude (i.e. adjusted RR of under-five mortality 1.03, 95% CI: 1.02-1.05).
  
  
  CONCLUSIONS
  Our analyses strongly suggest that the observed increased risk of mortality associated with high parity births is not driven by a physiological link between parity and mortality. We found that at each birth order, children born to women who have high fertility at the end of their reproductive period are at significantly higher mortality risk than children of mothers who have low fertility, even after adjusting for available confounders. With each unit increase in birth order, a larger proportion of births at the population level belongs to mothers with these adverse characteristics correlated with high fertility. Hence it appears as if mortality rates go up with increasing parity, but not for physiological reasons.
authors.forename: Naoko
authors.initials: N
authors.lastname: Kozuki
authors.forename: Emily
authors.initials: E
authors.lastname: Sonneveldt
authors.forename: Neff
authors.initials: N
authors.lastname: Walker
mesh_terms: D000328:Adult; D001721:Birth Intervals / Q000706:statistics & numerical data*; D015986:Confounding Factors, Epidemiologic; D019049:Developed Countries; D005260:Female; D006801:Humans; D007223:Infant; D007226:Infant Mortality / Q000639:trends*; D007229:Infant Welfare / Q000706:statistics & numerical data*; D008423:Maternal Age; D010298:Parity; D011203:Poverty / Q000706:statistics & numerical data*; D011247:Pregnancy; D012098:Reproduction; D012106:Research; D012424:Rural Population / Q000706:statistics & numerical data; D012959:Socioeconomic Factors; D014505:Urban Population / Q000706:statistics & numerical data