More Than 1.4 Million US Children Have Lost a Family Member to Drug Overdose.

Objectives. To estimate children's exposure to family overdose in the United States. Methods. We used recent demographic kinship modeling advances and the Centers for Disease Control and Prevention's most recent underlying cause of death estimates to model how many children aged younger than 18 years in 2019 had lost 1 or more parents, siblings, grandparents, aunts or uncles, or cousins to overdose mortality since birth. We calculated the number and proportion of children with such exposures and considered age, cohort, and gender patterning. Results. More than 1.4 million children in the United States, mostly adolescents, experienced a family overdose death, often losing central figures like parents or grandparents. Cohort analyses suggest dramatic increases in these exposures, portending mounting prevalence. Conclusions. Attention to the large population with lives disrupted by overdose deaths should include affected children. The long-arm consequences of the overdose crisis will continue to define the public health landscape for decades. (Am J Public Health. Published online ahead of print September 26, 2024:e1-e4. https://doi.org/10.2105/AJPH.2024.307847).

The Relationships between Drought Exposure, Fertility Preferences, and Contraceptive Behaviors: A Multicountry Study.

The interplay between population dynamics and the environment has long interested demographers. Although studies have explored how climate patterns affect macrolevel population processes, such as mortality and migration, little is known about their impact on individual-level demographic behaviors. This study fills this research gap by examining the linkages between exposure to drought and women's fertility preferences and contraceptive behaviors in sub-Saharan Africa. We analyze data from the Demographic and Health Surveys Program, focusing on 17 countries in East, Southern, and West Africa. We investigate whether women's recent exposure to drought episodes in their community affects their fertility preferences and modern contraceptive use. Generally, the findings show that drought is relevant to understanding women's fertility preferences and behaviors in the vast majority of countries; however, drought exposure has variable impacts. Moreover, whereas in some countries, drought exposure encourages contraceptive behaviors that align with women's preferences, in select countries it is associated with behavior that is misaligned with women's stated preferences. Overall, the study emphasizes the importance of examining climate events as complex forces that have localized meanings for demographic outcomes.

Intergenerational Clustering of Under-Five Mortality: A Cohort Perspective in Low- and Middle-Income Countries.

A burgeoning demographic literature documents the exceedingly high rates at which contemporary cohorts of women across the Global South experience the death of their children-even amid historic declines in child mortality. Yet, the patterning of maternal bereavement remains underinvestigated, as does the extent to which it replicates across generations of the same family. To that end, we ask: Are the surviving daughters of bereaved mothers more likely to eventually experience maternal bereavement? How does the intergenerational clustering of maternal bereavement vary across countries and cohorts? To answer these questions, we make use of Demographic and Health Survey Program data from 50 low- and middle-income countries, encompassing data on 1.05 million women and their mothers spanning three decadal birth cohorts. Descriptive results demonstrate that maternal bereavement is increasingly patterned intergenerationally across cohorts, with most women experiencing the same fate as their mothers. Multivariable hazard models further show that, on average, women whose mothers were maternally bereaved have significantly increased odds of losing a child themselves. In most countries, the association is stable across cohorts; however, in select countries, the risk associated with having a bereaved mother is shrinking among more recent birth cohorts.

Maternal cumulative prevalence measures of child mortality show heavy burden in sub-Saharan Africa.

We advance a set of population-level indicators that quantify the prevalence of mothers who have ever experienced an infant, under 5-y-old child, or any-age child die. The maternal cumulative prevalence of infant mortality (mIM), the maternal cumulative prevalence of under 5 mortality (mU5M), and the maternal cumulative prevalence of offspring mortality (mOM) bring theoretical and practical value to a variety of disciplines. Here we introduce maternal cumulative prevalence measures of mortality for multiple age groups of mothers in 20 sub-Saharan African countries with Demographic and Health Surveys data spanning more than two decades. The exercise demonstrates the persistently high prevalence of African mothers who have ever experienced a child die. In some African countries, more than one-half of 45- to 49-y-old mothers have experienced the death of a child under age 5, and nearly two-thirds have experienced the death of any child, irrespective of age. Fewer young mothers have experienced a child die, yet in many countries, up to one-third have. Our results show that the mIM and mU5M can follow distinct trajectories from the infant mortality rate (IMR) and under 5 mortality rate (U5MR), offering an experiential view of mortality decline that annualized measures conceal. These measures can be adapted to quantify the prevalence of recurrent offspring mortality (mROM) and calculated for subgroups to identify within-country inequality in the mortality burden. These indicators can be used to improve current understandings of mortality change, bereavement as a public health threat, and population dynamics.

Tracking the reach of COVID-19 kin loss with a bereavement multiplier applied to the United States.

The coronavirus disease 2019 (COVID-19) pandemic has led to a large increase in mortality in the United States and around the world, leaving many grieving the sudden loss of family members. We created an indicator-the COVID-19 bereavement multiplier-that estimates the average number of individuals who will experience the death of a close relative (defined as a grandparent, parent, sibling, spouse, or child) for each COVID-19 death. Using demographic microsimulation-based estimates of kinship networks in the United States, the clear age gradient in COVID-19 mortality seen across contexts, and several hypothetical infection prevalence scenarios, we estimate COVID-19 bereavement multipliers for White and Black individuals in the United States. Our analysis shows that for every COVID-19 death, approximately nine surviving Americans will lose a grandparent, parent, sibling, spouse, or child. These estimates imply, for example, that if 190,000 Americans die from COVID-19, as some models project, then ∼1.7 million will experience the death of a close relative. We demonstrate that our estimates of the bereavement multiplier are stable across epidemiological realities, including infection scenarios, total number of deaths, and the distribution of deaths, which means researchers can estimate the bereavement burden over the course of the epidemic in lockstep with rising death tolls. In addition, we provide estimates of bereavement multipliers by age group, types of kin loss, and race to illuminate prospective disparities. The bereavement multiplier is a useful indicator for tracking COVID-19's multiplicative impact as it reverberates across American families and can be tailored to other causes of death.

Is the mortality-fertility nexus gendered? A research note on sex differences in the impact of sibling mortality on fertility preferences.

Research guided by demographic transition theory has shown that exposure to mortality influences women's fertility preferences and behaviours. Despite the myriad contexts, methodological approaches, and linkages featured in past studies, they have shared a focus on women, leaving questions on the gendered salience of mortality exposures for adults' fertility-related outcomes unanswered. In this research note, we analyse data from three African countries with distinct fertility profiles (Nigeria, Zambia, and Zimbabwe) to examine associations between sibling mortality exposure and ideal family size among women, men, and couples. We also investigate the stability of these associations over time. The associations between adults' sibling mortality exposure and their own and their spouses' ideal family sizes vary across countries. However, the gendered nature of the results in every country and evidence of cross-spousal effects uniformly demonstrate the need to incorporate sex differences into the study of the mortality-fertility link.

Lost support, lost skills: Children's cognitive outcomes following grandparental death.

OBJECTIVE: This study examines the implications of grandparental death for cognitive skills in middle childhood. METHOD: This study uses data from the Future of Families and Child Wellbeing Study (N = 2479) to estimate ordinary least squares regression models of the associations between grandparental death and subsequent cognitive skills among children in middle childhood. RESULTS: Experiencing a grandparental death between ages 5 and 9 is associated with boys' lower reading, verbal, and math scores at age 9, with associations most notable for Black and Hispanic boys; grandparental death before age 5 has minimal influence on boys' cognitive skills at age 9. There is little indication that grandparental death adversely affects girls' cognitive skills. CONCLUSION: The numerous and persistent implications of grandparental death for boys' cognitive skills merit greater recognition of grandparental death as a source of family instability, stress, and ultimately inequality in child development.

Life After Loss: A Prospective Analysis of Mortality Exposure and Unintended Fertility.

The relationship between mortality and fertility is a key component of demographic transition theory, placing it at the center of extensive inquiry. Among other linkages, mortality in women's communities and social networks influences their subsequent fertility. Existing demographic research assumes this is principally due to volitional mechanisms, implying that exposure to mortality consolidates women's desire to become pregnant, leading to intended fertility. Yet, insights from other disciplines suggest that mortality exposure could also increase women's unintended fertility through psychological, relational, and behavioral mechanisms. This study examines the relationships between network mortality exposure and women's hazard of pregnancy, and of unintended pregnancy specifically. We analyze two years (2009-2011) of closely spaced panel data on young Malawian women (N=1,272) enrolled in the Tsogolo la Thanzi study. Our data include information on funeral attendance and fertility desires measured weeks before conception, which is confirmed through frequent pregnancy testing. Hazard models show that the number of funerals women attend corresponds with a higher hazard of pregnancy and of unintended pregnancy specifically. These findings make clear that mortality exposure can influence fertility not by shaping women's desires but by disrupting the realization of those desires.

Women's Life Experiences and Shifting Reports of Pregnancy Planning.

BACKGROUND: Unplanned pregnancy is associated with adverse consequences for women. Yet, these associations are typically based on women's reports of pregnancy planning provided post birth. Therefore, women's recollection of their pregnancy planning may be influenced by their adverse life circumstances following the pregnancy, artificially driving these associations. METHODS: To understand how post-birth experiences pattern women's recall of their pregnancy planning, we conducted 17 in-depth interviews with young women (24-34 years old) enrolled in a longitudinal study in southern Malawi. Respondents who were pregnant at the time of data collection in 2015 answered close-ended questions about the planning of their pregnancy. During in-depth interviews three years later, women discussed their life experiences since the pregnancy and were re-asked a subset of the same questions about the planning of the 2015 pregnancy. We thematically coded respondents' narratives about their relationships, parenting, and economic situations in the three years following their pregnancy and mapped these onto changes in women's pre- and post-birth reports of their pregnancy planning. RESULTS: More than one-half of respondents recalled their pregnancy planning differently than they did pre-birth-some as more planned, others as less planned. The presence and direction of women's changing reports were patterned by the quality of their relationship with the child's father, the father's involvement as a partner and parent, and their economic situation. CONCLUSIONS: Women's life experiences following a birth correspond with changes in their pregnancy planning reports, emphasizing the limitations of using retrospective measures to study the consequences of unplanned fertility.

Women's Health Decline Following (Some) Unintended Births: A Prospective Study.

BACKGROUND: As many as one-in-three unintended births occur in Africa. These births have the potential to adversely impact women's health, but data and design limitations have complicated efforts to understand their consequences. Moreover, there is growing evidence that women often feel happy about an unintended pregnancy and this heterogeneity may be important for identifying the births that are - and those that are not - harmful to women's health. OBJECTIVE: To assess whether having an unintended birth precipitates health declines for young women in a high-fertility, high-morbidity context, and whether women's emotional reaction to the pregnancy foreshadows the consequences of the resulting birth. METHODS: We use closely spaced panel data from 896 young women in Malawi that include prospective measures of fertility timing desires captured only months before conception and a contemporaneous measure of emotional reaction to the pregnancy. We run lagged dependent variable regression models of self-rated health that account for health and sociodemographic conditions prior to pregnancy and compare women with unintended births to women with intended births and to an alternative comparison group: women who avoid an unintended birth. We then disaggregate unintended births by women's emotional reaction after learning of the pregnancy. RESULTS: Women who had an unintended birth but initially had a positive reaction to the pregnancy did not experience a decline in health after birth. Women who had a more negative reaction, however, experienced marked reductions in self-rated health, even years after the birth. CONTRIBUTION: Our findings highlight meaningful heterogeneity in the consequences of unintended fertility for women's health and offer insights into the unintended births that put women at greatest risk of health decline.

Does Parents' Union Instability Disrupt Intergenerational Advantage? An Analysis of Sub-Saharan Africa.

The long arm of childhood, with its wide-ranging influence on individuals' life chances, highlights the importance of understanding the determinants of health in early life. Research has established that parents' education is a major determinant of childhood health, but children across the globe increasingly experience their parents' divorce and subsequent remarriage, raising questions of whether union instability alters these intergenerational processes. Does divorce and remarriage interfere with parents' education benefiting their young children's health? I explore this question in sub-Saharan Africa, a world region where parents' education plays a major role in protecting children against severe health risks, and where young children commonly experience parental divorce and remarriage. Moreover, sub-Saharan Africa features distinct family lineage systems, affording an opportunity to explore this question in both majority matrilineal and patrilineal contexts. Analyses of Demographic and Health Survey data on 271,292 children in 30 sub-Saharan African countries offer no evidence that the high levels of union instability in the region will weaken the health benefits of parents' education for future generations. Following divorce, children benefit from their biological parents' education to the same degree as children with married parents-a finding that is consistent across lineage contexts. Moreover, stepfathers' education corresponds with pronounced health benefits for their coresident stepchildren, particularly in patrilineal regions where these children benefit less dramatically from their mothers' education. Together, the study results offer a renewed sense of the importance of parents'-including stepfathers'-education for early childhood health across diverse family structures.

The Marital Implications of Bereavement: Child Death and Intimate Partner Violence in West and Central Africa.

In high-mortality contexts, research examining the effects of child mortality has focused almost exclusively on couples' fertility responses while overlooking other potential family consequences. Using nationally representative survey data from 13 West and Central African countries, we estimate multilevel discrete-time hazard models to determine how women's risk of intimate partner violence (IPV) varies with the death of children. We assess heterogeneity in this association across two surrounding circumstances: children's age at death and regional prevalence of child bereavement. Findings indicate that the risk of IPV initiation rises with the death of children under age 5-for whom women are most intensely responsible-but not with the death of older children. The effect of young child bereavement is most pronounced in regions where it is least prevalent among mothers-a finding not explained by concomitant regional variation in gender inequality, family norms, and infrastructural development. These findings highlight the importance of child mortality for family outcomes beyond fertility in the African context and demonstrate the prominent role of the broader mortality context in shaping these implications.

Birth Planning and Women's and Men's Health in Malawi.

Despite the frequency with which it occurs, we know little about unintended fertility in sub-Saharan Africa and even less about its implications for the health of the women and men who experience it. We use longitudinal data from southern Malawi to explore how young adults report on the planning of their births and to identify changes in their self-rated health and subjective well-being associated with having more- or less-planned births. Our data feature a comprehensive scale of pregnancy planning, the London Measure of Unplanned Pregnancy (LMUP), that extends beyond the conventional focus on timing-based pregnancy intentions to incorporate information about contraception, desires, intentions, partner discussion, and preconception preparations. Women and men have similar bimodal distributions on the LMUP, with the majority of births clearly unplanned or planned but a sizeable minority that falls in the middle. Change score models demonstrate that, for women, an unplanned birth is associated with a decline in self-rated health. In contrast, men whose births were ambivalently-planned experience a decline in subjective well-being. Our findings highlight the value of considering the full spectrum of birth planning and demonstrate the health consequences of unplanned fertility for both women and men in this sub-Saharan context.

Offspring education and parental mortality: Evidence from South Asia.

Decades of research show that education not only confers individual health benefits, but it also spills over to advantage subsequent generations. More recently, research has confirmed that the intergenerational health benefits of education can also flow upward: aging adults with more highly educated children experience better health and higher survival. Research has documented this finding in high-income settings, and also in select low- and middle-income contexts, raising questions about how having an adult child who attended relatively low levels of education can benefit aging parents' well-being. In this study, we use multilevel, long-term panel data on a cohort of older adults from the Chitwan Valley Family Study in rural Nepal to establish whether the association between offspring education and parents' survival is observable in this extremely poor, agrarian context. Extending past studies, we then leverage additional data on older adults to examine the association between offspring education and two theorized mechanisms: older adults' better health behaviors and their greater support in later life.

Recent Trends in Premarital Fertility across Sub-Saharan Africa.

The rising age of first marriage across sub-Saharan Africa over the past 25 years has led many scholars to predict a concurrent increase in premarital childbearing. We examine whether this anticipated increase has materialized using data from 27 countries. Our results reveal considerable heterogeneity. Although levels of premarital fertility have risen by up to 13 percent in recent years in some African countries, other countries have experienced a 7 percent decline. Adolescent premarital childbearing, in particular, has shown marked decline in several countries. Furthermore, although the rising age of marriage exerts clear upward pressure on premarital fertility, decomposition analyses indicate that in half of the countries examined, other factors such as delayed sexual debut and use of contraception counteract this effect. These results temper concerns about the rising numbers of unwed mothers and demonstrate that countries can simultaneously delay marriage and achieve relatively stable, or even declining, levels of premarital childbearing.

Emotional Variation and Fertility Behavior.

Emotional influences on fertility behaviors are an understudied topic that may offer a clear explanation of why many couples choose to have children even when childbearing is not economically rational. With setting-specific measures of the husband-wife emotional bond appropriate for large-scale population research matched with data from a long-term panel study, we have the empirical tools to provide a test of the influence of emotional factors on contraceptive use to limit fertility. This article presents those tests. We use long-term, multilevel community and family panel data to demonstrate that the variance in levels of husband-wife emotional bond is significantly associated with their subsequent use of contraception to avert births. We discuss the wide-ranging implications of this intriguing new result.

Death and Desirability: Retrospective Reporting of Unintended Pregnancy After a Child's Death.

Social scientists have long debated how to best measure pregnancy intentions. The standard measure relies on mothers' retrospective reports of their intentions at the time of conception. Because women have already given birth at the time of this report, the resulting children's health-including their vital status-may influence their mothers' responses. We hypothesize that women are less likely to report that deceased children were from unintended pregnancies, which may explain why some cross-sectional studies have shown that children from unintended pregnancies have higher survival, despite the fact that longitudinal studies have shown the opposite is true. Using Demographic and Health Survey data from 31 sub-Saharan African countries, we confirm that mothers are less likely to report that deceased children resulted from unintended pregnancies compared with surviving children. However, the opposite is true for unhealthy children: mothers more commonly report that unhealthy children were from unintended pregnancies compared with healthier children. The results suggest that mothers (1) revise their recall of intentions after the traumatic experience of child death and/or (2) alter their reports in the face-to-face interview. The study challenges the reliability of retrospective reports of pregnancy intentions in high-mortality settings and thus also our current knowledge of the levels and consequences of unintended pregnancies in these contexts.

Household sanitation facilities and women's risk of non-partner sexual violence in India.

BACKGROUND: Globally, one in ten individuals practice open defecation. Despite media speculation that it increases women's risk of sexual violence, little empirical evidence supports the claims. We investigate the relationship between household sanitation facilities and women's risk of non-partner sexual violence (NPSV) in India, where nearly half of the population lives without a pit or toilet. METHODS: We use the most recent NPSV data, from the National Family Health Survey-III, to estimate logistic regression models of the effects of household sanitation facilities (toilet, pit, or none) on NPSV in the last year among women who have resided in their current home for one year or more. These effects are estimated net of other socioeconomic factors, compared to effects of household sanitation facilities on child diarrhea, and, as a falsification test, compared to effects of household sanitation facilities on intimate partner sexual violence (IPSV) in the last year. RESULTS: Net of their socioeconomic status, women who use open defecation are twice as likely to face NPSV as women with a household toilet. This is twice the association between open defecation and child diarrhea. The results of our falsification test indicate that open defecation is not correlated with IPSV, thus disconfirming a simultaneous selection of women into open defecation and sexual violence. CONCLUSIONS: Our findings provide empirical evidence that lacking household sanitation is associated with higher risk of NPSV.

Maternal migration and child health: An analysis of disruption and adaptation processes in Benin.

Children of migrant mothers have lower vaccination rates compared to their peers with non-migrant mothers in low-income countries. Explanations for this finding are typically grounded in the disruption and adaptation perspectives of migration. Researchers argue that migration is a disruptive process that interferes with women's economic well-being and social networks, and ultimately their health-seeking behaviors. With time, however, migrant women adapt to their new settings, and their health behaviors improve. Despite prominence in the literature, no research tests the salience of these perspectives to the relationship between maternal migration and child vaccination. We innovatively leverage Demographic and Health Survey data to test the extent to which disruption and adaptation processes underlie the relationship between maternal migration and child vaccination in the context of Benin-a West African country where migration is common and child vaccination rates have declined in recent years. By disaggregating children of migrants according to whether they were born before or after their mother's migration, we confirm that migration does not lower children's vaccination rates in Benin. In fact, children born after migration enjoy a higher likelihood of vaccination, whereas their peers born in the community from which their mother eventually migrates are less likely to be vaccinated. Although we find no support for the disruption perspective of migration, we do find evidence of adaptation: children born after migration have an increased likelihood of vaccination the longer their mother resides in the destination community prior to their birth.

Impact of the spread of mass education on married women's experience with domestic violence.

This paper investigates the association between mass education and married women's experience with domestic violence in rural Nepal. Previous research on domestic violence in South Asian societies emphasizes patriarchal ideology and the widespread subordinate status of women within their communities and families. The recent spread of mass education is likely to shift these gendered dynamics, thereby lowering women's likelihood of experiencing domestic violence. Using data from 1775 currently married women from the Chitwan Valley Family Study in Nepal, we provide a thorough analysis of how the spread of mass education is associated with domestic violence among married women. The results show that women's childhood access to school, their parents' schooling, their own schooling, and their husbands' schooling are each associated with their lower likelihood of experiencing domestic violence. Indeed, husbands' education has a particularly strong, inverse association with women's likelihood of experiencing domestic violence. These associations suggest that the proliferation of mass education will lead to a marked decline in women's experience with domestic violence in Nepal.