This analysis has identified several factors contributing to the dramatic decline in infant mortality since World War II in Malaysia, as well as one factor that prevented the infant mortality rate from declining even more rapidly. Our main findings are the following: On average, mothers' education more than doubled over the study period, contributing to the decline in their infants' mortality. In addition, the beneficial effect of mothers' education on infant survival appears to have become stronger over the study period. Hence, further advances in education should lead to further improvements in infants' survival prospects. Another analysis of these data (Peterson et al. 1985) found that education is somewhat more influential in affecting child mortality in low-mortality, high-income areas than in the opposite type of areas. Therefore, socioeconomic development may have complemented, instead of substituted for, the the beneficial effect of mothers' education in promoting infant and child survival in Malaysia. Improvements in water and sanitation also contributed to the infant mortality decline, especially for babies who did not breastfeed. However, unlike education, these influences have become less important over time, especially for babies who are not breastfed. Hence, further improvements in water and sanitation, a goal of Malaysia's Rural Environmental Sanitation Programme, may have smaller relative effects on infant mortality than did previous improvements. Targeting such improvements on areas where women breastfeed little or not at all, however, will increase their effectiveness in promoting infant survival. The substantial reductions in breastfeeding that have taken place since World War II have kept the infant mortality rate in Malaysia from declining as rapidly as it would have otherwise. We estimate that, in our sample, the detrimental effects on infant survival of the decline in breastfeeding have more than offset the beneficial effects of improvements in water and sanitation. Unlike some other researchers (e.g., Palloni 1981), we find that changes in fertility levels and in the timing and spacing of births have had negligible effect in explaining the decline in infant mortality within the samples we have considered. We have excluded births to older women from our analysis, however; this exclusion may have led to an understatement of the influence of changes in the age pattern of childbearing.(ABSTRACT TRUNCATED AT 400 WORDS)
The effect of toilets, piped water, and maternal literacy on infant mortality was analyzed using data from the Malaysian Family Life Survey collected in 1976-1977. The effect of toilets and piped water on infant mortality was dependent on whether or not mothers were literate. The impact of having toilets was greater among the illiterate than among the literate, but the impact of piped water was greater among the literate than among the illiterate. The effect on the infant mortality rate for toilets decreased from 130.7 +/- 17.2 deaths in the absence of literate mothers to 76.2 +/- 25.9 deaths in the presence of literate mothers. The reduction in the mortality rate for maternal literacy dropped from 44.4 +/- 14.1 deaths without toilets to -10.1 +/- 23.9 deaths with toilets. Reductions in mortality rates for piped water increased from 16.7 +/- 12.7 deaths without literate mothers to 36.8 +/- 21.0 deaths with literate mothers. Similarly, reductions in the mortality rate for maternal literacy rose from 44.4 +/- 14.1 deaths in the absence of piped water to 64.5 +/- 19.5 deaths in the presence of piped water. The results from a logistic model provided inferences similar to those from ordinary least squares. The authors infer that literate mothers protect their infants especially in unsanitary environments lacking toilets, and that when piped water is introduced, they use it more effectively to practice better hygiene for their infants.
If they lived in households without piped water or a toilet, Malaysian infants who did not breast-feed were five times more likely to die after 1 week of age than those who breast-fed, when other significant factors affecting infant mortality were taken into account. This is double the relative risk associated with not breast-feeding for infants born into households with toilets, whether or not they had piped water. Analogously, improvements in toilet sanitation appear to have reduced mortality twice as much among infants who did not breast-feed as among those who did. These findings, from a retrospective survey of infants born to a probability sample of 1,262 women in peninsular Malaysia, confirm the pernicious synergistic effect of poor sanitation and nonbreastfeeding that was postulated previously on theoretical grounds. Promoting and maintaining high initiation of breast-feeding is thus particularly important where poor sanitation is prevalent. Even more affluent areas should not be neglected, however, because socioeconomic improvement, including improved environmental sanitation, is often accompanied by decreased breast-feeding. Although the risk to each nonbreast-fed infant was less in those areas, infants there were less likely to breast-feed in Malaysia, and hence they made up a significant proportion of lives that could be saved by breast-feeding.
Mothers' recall data collected in Malaysia in 1976-1977 are analyzed to study correlates of mortality of 5471 infants. Respondent population is 1262 women living in 52 primary sampling units of Peninsular Malaysia. Lengths of unsupplemented and supplemented breastfeeding and presence of piped household water and toilet sanitation are related to infant mortality in regressions that also control other correlates. The analysis is disaggregated into three periods of infancy. Through six months of feeding, unsupplemented breastfeeding is more strongly associated with fewer infant deaths than is supplemented breastfeeding. Type of sanitation is generally more strongly associated with mortality than is type of water supply. The effects of breastfeeding and the environmental variables are shown to be strongly interactive and to change systematically during the course of infancy. Breastfeeding is more strongly associated with infant survival in homes without piped water or toilet sanitation. In homes with both modern facilities, supplemented breastfeeding has no significant effect, and unsupplemented breastfeeding is statistically significant only for mortality in days 8-28. Presence of modern water and sanitation systems appears unimportant for mortality of infants who are breastfed without supplementation for six months.
Analysis of mothers' recall data collected in 1976-1977 by a probability survey in Peninsular Malaysia shows an association between breastfeeding up to six months of age and improved survival of infants throughout the first year of life. Inappropriate sample selection and inadequate control of confounding can introduce large biases in these analyses. The magnitude and direction of these biases are presented. Even when these biases are dealt with, unsupplemented breastfeeding appears more beneficial than supplemented breastfeeding. The younger the infant and the longer the breastfeeding, the greater the estimated benefits in terms of deaths averted. The use of powdered infant formula did not appear to offset the detrimental effects of early weaning and supplementation. The positive relationships found in these analyses between breastfeeding and survival are not due to death precluding or terminating breastfeeding. Nor are they likely to be due to a shift away from breastfeeding because of recent illness, which was also controlled in the analyses. Nor are they likely to be due to other factors that both increase mortality risk and shorten breastfeeding; when such factors are taken into account, the beneficial effects of breastfeeding become stronger and imply that, if there had been no breastfeeding in this sample, twice as many babies would have died after the first week of life.
This paper presents evidence from the Malaysian Family Life Survey that mothers' reports of their babies' birthweights, including reports of unweighed babies' approximate size at birth, can be used to examine many biological and socioeconomic correlates of birthweight. The study uses a sample of 5583 singleton births that occurred between 1945 and 1976. In these data, the frequency distribution of birthweights and their bivariate and multivariate relationships with the biological correlates of mother's age, baby's sex, first parity and infant mortality are consistent with those found in prospective studies. A new biological correlate, mother's age at menarche, is introduced as a proxy for the mother's nutrition during childhood. Late age at menarche is associated with lower birthweight. Other results show mothers younger than 20 years and older than 35 appear to be at greater risk of bearing small babies, but the former effect is no longer important when parity is controlled. Short interbirth intervals are associated with small babies. We attempt to distinguish whether this is due to prematurity or to maternal nutritional depletion; both effects appear to be operating. Higher income appears to mitigate the pernicious effect of short interbirth intervals. Indian babies weigh significantly less than those of other ethnic groups. Furthermore, birthweights have increased since the 1950s for Malays and Chinese, but not for Indians. The lower birthweights and lack of improvement over time for Indians appear to be due to close birthspacing, lack of access to medical care and falling incomes.