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The majority of studies of the birth spacing–child survival relationship rely on retrospective data, which are vulnerable to errors that might bias results. The relationship is re-assessed using prospective data on 13,502 children born in two Nairobi slums between 2003 and 2009. Nearly 48% were first births. Among the remainder, short preceding intervals are common: 20% of second and higher order births were delivered within 24 months of an elder sibling, including 9% with a very short preceding interval of less than 18 months. After adjustment for potential confounders, the length of the preceding birth interval is a major determinant of infant and early childhood mortality. In infancy, a preceding birth interval of less than 18 months is associated with a two-fold increase in mortality risks (compared with lengthened intervals of 36 months or longer), while an interval of 18–23 months is associated with an increase of 18%. During the early childhood period, children born within 18 months of an elder sibling are more than twice as likely to die as those born after an interval of 36 months or more. Only 592 children experienced the birth of a younger sibling within 20 months; their second-year mortality was about twice as high as that of other children. These results support the findings based on retrospective data.

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APHRC (African Population and Health Research Center) (2002) Population and Health Dynamics in Nairobi's Informal Settlements. African Population and Health Research Center, Nairobi, Kenya.
Becher, H., Muller, O., Jahn, A., Gbangou, A., Kynast-Wolf, G. & Kouyaté, B. (2004) Risk factors of infant and child mortality in rural Burkina Faso. Bulletin of the World Health Organization 82, 265275.
Black, R. E., Morris, S. S. & Bryce, J. (2003) Where and why are 10 million children dying every year? The Lancet 361, 22262234.
Bocquier, P., Beguy, D., Zulu, E., Muindi, K., Konseiga, A. & Ye, Y. (2011) Do migrant children face greater health hazards in slum settlements? Evidence from Nairobi, Kenya. Journal of Urban Health 88, 266281.
Boerma, J. T. & Bicego, G. (1992) Preceding birth intervals and child survival: searching for pathways of influence. Studies in Family Planning 23, 243256.
Boerma, J. T. & Van Vianen, H. A. W. (1984) Birth interval, mortality and growth of children in a rural area in Kenya. Journal of Biosocial Science 16, 475486.
Brockerhoff, M. P. (2000) An urbanizing world. Population Bulletin, 55.
Bryce, J., Black, R. E., Walker, N., Buttha, Z. A., Lawn, J. E. & Steketee, R. W. (2005) Can the world afford to save the lives of 6 million children each year? The Lancet 365, 21932200.
CBS (Central Bureau of Statistics) (2005) Welfare Monitoring Survey III: Government Priorities. Ministry of Planning and National Development, Nairobi.
Cleland, G. J., Bernstein, S., Ezeh, A., Anibal, F.Anna, G. & Jolene, I. (2006) Family planning: the unfinished agenda. The Lancet 368, 18101827.
Cleland, G. J. & Sathar, Z. A. (1984) The effect of birth spacing on childhood mortality in Pakistan. Population Studies 38, 401408.
Cohen, B. (2004) Urban growth in developing countries: a review of current trends and a caution regarding existing forecast. World Development 32, 2351.
Conde-Agudelo, A., Rosas-Bermúdez, A. & Kafury-Goeta, A. C. (2006) Birth spacing and the risk of adverse perinatal outcomes: a meta-analysis. Journal of the American Medical Association 295, 18091923.
Curtis, S. L. (1995) Assessment of the Quality of Data Used for Direct Estimation of Infant and Child Mortality in DHS-11 Surveys. DHS Occasional Report 3. Macro International, Inc., Calverton, MD.
Curtis, S. L., Diamond, I. & McDonald, J. W. (1993) Birth interval and family effects on postneonatal mortality in Brazil. Demography 33, 3343.
Davanzo, J., Hale, L., Razzaque, A. & Rahman, M. (2008) The effects of pregnancy spacing on infant and child mortality in Matlab, Bangladesh: how they vary by the type of pregnancy outcome that began the interval. Population Studies 62, 131154.
Doyle, P., Morley, D., Woodland, M. & Cole, J. (1978) Birth intervals, survival and growth in a Nigerian village. Journal of Biosocial Science 10, 8194.
Emina, J., Beguy, D., Zulu, E., Ezeh, A., Muindi, K., Elung'ata, P., Otsola, J. K. & , Y. (2011) Monitoring of health and demographic outcomes in poor urban settlements: evidence from the Nairobi Urban Health and Demographic Surveillance System. Journal of Urban Health 88, 200218.
Essendi, H., Mills, S. & Fotso, J. C. (2011) Barriers to formal emergency obstetric care services' utilization. Journal of Urban Health 88, 356369.
Faye, O., Falkingham, J., Baschieri, A. & Muindi, K. (2011) Hunger and food insecurity in Nairobi's slums: an assessment using IRT models. Journal of Urban Health 88, 235255.
Fotso, J. C. (2006) Child health inequities in developing countries: differences across urban and rural areas. International Journal of Equity in Health 5, 110.
Fotso, J. C., Ezeh, A., Madise, N. & Ciera, J. (2007) Progress towards the child mortality millennium development goal in urban sub-Saharan Africa: the dynamics of population growth, immunization, and access to clean water. BMC Public Health, 7.
Fotso, J. C., Madise, N., Baschieri, A., Cleland, J., Zulu, E., Mutua, M. & Essendi, H. (2012) Child growth in urban deprived settings: does household poverty status matter? At which stage of child development? Health & Place 18, 375384.
Friberg, I. K., Kinney, M. V., Lawn, J. E., Kerber, K. J., Odubanjo, M. al. (2010) Sub-Saharan Africa's mothers, newborns, and children: how many lives could be saved with targeted health interventions? PLoS Medicine 7(6), e1000295. doi:10.1371/journal.pmed.1000295
Gipson, J. D., Koenig, M. A. & Hindin, M. J. (2008) The effects of unintended pregnancy on infant, child, and parental health: a review of the literature. Studies in Family Planning 39, 1838.
Gould, W. T. S. (1998) African mortality and the new ‘urban penalty’. Health and Place 4, 171181.
Hobcraft, J., McDonald, J. W. & Rutstein, S. O. (1983) Child-spacing effects on infant and early child mortality. Population Index 49, 585618.
Hobcraft, J., McDonald, J. W. & Rutstein, S. O. (1985) Demographic determinants of infant and early child mortality: a comparative analysis. Population Studies 39, 363385.
IRD (Institute for Resource Development) (1990) An Assessment of DHS-1 Data Quality. DHS Methodological Report 1. Macro International, Inc., Calverton, MD.
Jones, G., Steketee, R. W., Black, R. E., Buttha, Z. A., Morris, S. S. & The Bellagio Child Survival Study Group (2003) How many child deaths can we prevent this year? The Lancet 362, 6571.
Kimani-Murage, E. W., Madise, N., Fotso, J. C., Kyobutungi, C., Mutua, M. K., Gitau, T. & Yatich, Y. (2011) Patterns and determinants of breastfeeding and complementary feeding practices in urban informal settlements, Nairobi Kenya. BMC Public Health, 11.
KNBS (Kenya National Bureau of Statistics) & Ministry of Planning National Development and Vision 2030 (2009) Kenya Population and Housing Census 2009. KNBS, Nairobi.
Kuate-Defo, B. (1997) Effects of infant feeding practices and birth spacing on infant and child survival: a reassessment from retrospective and prospective data. Journal of Biosocial Science 29, 303326.
Manda, S. O. M. (1999) Birth intervals, breastfeeding and determinants of childhood mortality in Malawi. Social Science & Medicine 48, 301312.
Mercado, S. & Havemann, S. M. (2007) Urban poverty: an urgent public health issue. Journal of Urban Health 84, i715.
Miller, J. E., Trussell, J., Pebley, A. R. & Vaughan, B. (1992) Birth spacing and child mortality in Bangladesh and the Philippines. Demography 29, 305318.
Mohan, P. (2005) Inequities in coverage of preventive child health interventions: the rural drinking water supply program and the universal immunization program in Rajastahn, India. American Journal of Public Health 95, 241244.
Moreland, S. & Talbird, S. (2006) Achieving the Millennium Development Goals: The Contribution of Fulfilling the Unmet Need for Family Planning. Futures Group/POLICY Project and USAID.
Ndugwa, R., Cleland, J., Madise, N., Fotso, J. C. & Zulu, E. (2011) Menstrual pattern, sexual behaviors, and contraceptive use among postpartum women in Nairobi urban slums. Journal of Urban Health 88, 341355.
Norton, M. (2005) New evidence on birth spacing: promising findings for improving newborn, infant, child, and maternal health. International Journal of Gynecology and Obstetrics 89, S16.
Pebley, A. R. & Stupp, P. W. (1987) Reproductive patterns and child mortality in Guatemala. Demography 24, 4360.
Potter, J. E. (1988) Birth spacing and child survival: a cautionary note regarding the evidence from the WFS. Population Studies 42, 443450.
Pullum, T. W. (2006) An Assessment of Age and Date Reporting in the Demographic and Health Surveys, 1985-2003. DHS Methodological Reports 5. Macro International, Inc., Calverton, MD.
Retherford, R. D., Minja, K. C., Shyam, T. & Gubhaju, B. B. (1989) To what extent does breastfeeding explain birth-interval effects on early childhood mortality? Demography 26, 439450.
Ronsmans, C. (1996) Birth spacing and child survival in rural Senegal. International Journal of Epidemiology 25(5), 989997.
Royston, P. (2005) Multiple imputation of missing values: update of ice. Stata Journal 5, 527536.
Rutstein, S. O. (2008) Further evidence of the effects of preceding birth intervals on neonatal, infant, and under-five-years mortality and nutritional status in developing countries: evidence from the demographic and health surveys. DHS Working Papers Series.
Rutstein, S. O., Johnson, K., Conde-Agudelo, A. & Rosas-Bermudez, A. (2005) Effect of birth spacing on infant and child mortality: a systematic review and meta-analysis. In World Health Organization Consultation and Scientific Review of Birth Spacing. WHO, Geneva, 13–15th June 2005.
Singh, S., Sedgh, G. & Hussain, R. (2010) Unintended pregnancy: worldwide levels, trends, and outcomes. Studies in Family Planning 41, 241250.
Smith, R., Ashford, L., Gribble, J. & Clifton, D. (2009) Family Planning Saves Lives. Population Reference Bureau.
Smits, L. J. & Essed, G. G. (2001) Short interpregnancy intervals and unfavourable pregnancy outcome: role of folate depletion. The Lancet 358, 20742077.
UN (United Nations) (1994) The Health Rationale for Family Planning: Timing of Births and Child Survival. Department for Economic and Social Information and Policy Analysis, Population Division, United Nations, New York.
UN (United Nations) (2010) World Urbanization Prospects: The 2009 Revision. Department of Economic and Social Affairs, Population Division, United Nations, New York.
UN (United Nations) (2011) The Millennium Development Goals Report 2011. United Nations, New York.
UNDP (2003) Achieving the Millennium Development Goals: Population and Reproductive Health as Critical Determinants. Population and Development Strategies Series, UNDP, New York.
USAID (2002) Birth Spacing: Three to Five Saves Lives. Johns Hopkins Bloomberg School of Public Health's Center for Communication Programs.
Westoff, C. (2010) Birth Spacing and Limiting Connections. DHS Analytical Study 21. Macro International, Inc., Calverton, MD.
Whitworth, A. & Stephenson, R. (2002) Birth spacing, sibling rivalry and child mortality in India. Social Science & Medicine 55, 21072119.
WHO (World Health Organization) (2005) Report of a WHO Technical Consultation on Birth Spacing. WHO, Geneva.
Wolfers, D. & Scrimshaw, S. (1975) Child survival and intervals between pregnancies in Guayaquil, Ecuador. Population Studies 29, J479496.
World Bank (2010) Lessons from a Review of Interventions to Reduce Child Malnutrition in Developing Countries: What Can We Learn from Nutrition Impact Evaluations? The World Bank, Washington, DC.
Zulu, E., Beguy, D., Ezeh, A., Bocquier, P., Nyovani, M., Cleland, J. & Falkingham, J. (2011) Overview of migration, poverty and health dynamics in Nairobi city's slum settlements. Journal of Urban Health 88, 185199.
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Journal of Biosocial Science
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