Prenatal development in rural South Africa:

Relationship between birth weight and access

to fathers and grandparents
Solveig Argeseanu Cunningham,1 Irma T. Elo,2 Kobus Herbst,3 and Victoria Hosegood3,4
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Abstract
Birth weight is an indicator of prenatal development associated with health in infancy and
childhood, and may be affected by the family environment experienced by the mother during
pregnancy. Using data from KwaZulu-Natal, South Africa, we explore the importance of the
mother's access to the father and grandparents of the child during pregnancy. Controlling for
household socio-economic indicators and maternal characteristics, the survival and residence of
the biological father with the mother are positively associated with birth weight. The type of
relationship seems to matter: married women have the heaviest newborns, but co-residence with
a non-marital partner is also associated with higher birth weight. Access to the maternal
grandmother may also be important: women whose mothers are alive have heavier newborns, but
no additional benefit is observed from residing together. Co-residence with any grandparent is
not associated with birth weight after controlling for the mother's partnership.

Keywords: birth weight, child health, family, grandmother, father, partnership, South Africa
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Introduction
Weight at birth is an indicator of foetal health and subsequent survival, development, and health
(Hack et al. 1994; Barker 1995; Solis et al. 2000; Behrman and Rosenzweig 2004; Evensen et al.
2004). The family environment can be an important source of support during pregnancy, and this
support may improve maternal health and nutrition and consequently alsofect birth weight.
Studies from the USA and Europe have shown that birth weight is positively associated with the
mother's social support, including her marital status and her access to the child's father (Miller
1991; Manderbacka et al. 1992; Reichman and Pagnini 1997; Bird et al. 2000; Dunkel-Schetter
2000; Feldman et al. 2000). The contribution of the study we report here was to explore the
importance of the family environment for birth weight in a less developed country. Using data
from a longitudinal, population-based data-set in KwaZulu-Natal province, South Africa, we
examined the possible impact on birth weight of access to the child's biological father or other
partner of the mother, and to grandparents, especially the mother's mother. There is evidence that
family and household structure are important for several aspects of child well-being in less
developed countries. For example, studies have shown that children who do not live with both
parents (Engle and Breaux 1998; Morrell et al. 2003; Richter 2006) or whose parents are
deceased (Bishal et al. 2003; Case et al. 2004; Newell et al. 2004; Case and Ardington 2006;
Evans and Miguel 2007) have worse outcomes in terms of survival, growth, education, and
psychological wellbeing. There is also evidence that the presence of maternal grandmothers
improves child growth and survival (Sear et al. 2000; Duflo 2003).

The family environment may be particularly important to consider in South Africa, where multi-
generational households are common, ratesof marriage are low, and where the social and
residential arrangements are a legacy of the labour migration system created during the apartheid
era (Preston-Whyte 1993; Niehaus 1994; Russell 2003; Montgomery et al. 2006; Ramphele and
Richter 2006; Wilson 2006). In South Africa, only 37 per cent of children lived with both
biological parents in 2005 (Budlender 2006), and in the population described here, 15 and 51 per
cent of children under 18 years old were not members of the same household as their mother and
father respectively (Hill et al. 2008).

We focused on birth weight as a direct measure of prenatal development because it is an

indicator both of intrauterine nutrition and growth and of duration of gestation. Unlike mortality,
which is the more commonly studied indicator of child health, birth weight, because it is a
continuous variable, permits more nuanced analyses of family support and child health.

Social support, family environment, and health at birth

Social support comprises the resources acquired through social contacts to meet both routine and
extraordinary needs (Lin and Ensel 1989). It is widely believed to be an important component of
mental, social, and physical well-being. Social support may affect health directly, mediate the
effects of life events on health, or it may buffer the consequences of negative events (Lin and
Ensel 1989). One of the most important institutions within which supportive exchanges occur is
the family (Astone et al. 1999).

Studies conducted in the USA and Europe have shown that social support is associated with
better child health at birth. These studies highlight the importance of social networks and
perceived support from a male partner and to a lesser extent perceived support from family
members (Ramsey et al. 1986; Pagel et al. 1990; Mutale et al. 1991; Dunkel-Schetter et al.
2000). Women with multiple sources of support from their family, the child's father, or a social
network give birth to heavier babies, with these relationships being as predictive as medically
defined obstetric risk factors (Feldman et al. 2000). Social support has been generally shown to
be associated with birth weight in the process of foetal growth (Feldman et al. 2000). Thus
family support may be of greater benefit in resource-poor settings, where mothers are more
likely to be exposed to nutritional insufficiencies that can restrict foetal growth.

Grandparents and child health

A number of studies have examined the importance of grandparents for child survival. In
historical Germany and Québéc, infants aged 6–12 months and toddlers whose maternal
grandmothers were still alive were more likely to survive, especially if the grandmother lived
close by (Voland and Beise 2002; Beise 2005). Among present-day Khasi in North-east India,
children whose maternal grandmothers were alive but not co-resident with them had lower
chances of dying before the age of 10 than were children with deceased grandmothers (Leonetti
et al. 2005). A study in Gambia found that children past infancy who had living maternal
grandmothers had significantly lower mortality than those whose maternal grandmothers had
died, though co-residence did not increase the benefits (Sear et al. 2002). A recent review of the
literature reports that, among 11 statistically valid studies examining the effects of the maternal
grandmother on child survival, seven found positive associations, one found negative
associations, and three found no associations (Sear and Mace 2008). Most of the statistically
valid studies also found positive effects of paternal grandmothers (9 of 15), but among studies
estimating the effects of grandfathers, the largest number found no effect for maternal (8 out of
10) or paternal (5 out of 10) grandfathers (Sear and Mace 2008).

Children's health may benefit in other respects from grandparental care. In Gambia, the survival
of the maternal grandmother was associated with better nutritional status in early childhood,
measured by weight and height, but only if the maternal grandmother was not herself
reproductively active (Sear et al. 2000). In KwaZulu-Natal, South Africa, in a population near
the one featured in our study, height and weight increased more in children living with
grandmothers (but not grandfathers) eligible for the State old-age pension than in children living
with ineligible grandmothers, though effects were significant only for granddaughters and not for
grandsons (Duflo 2003). Qualitative research from our study population in KwaZulu-Natal found
that young mothers sought parenting help from their mothers and grandmothers, though the
guidance they received from family with respect to infant feeding was often incompatible with
recommended practices (Thairu et al. 2005).

There are reasons to expect that grandparents, and especially grandmothers, may also influence
prenatal development. A grandmother may be able to improve prenatal health through financial
support(for example, purchasing more food and more nutritious food or paying for transportation
or medical expenses), reducing the mother's workload (for example, caring for her other children,
cooking, cleaning, or fetching water), or recognizing health complications. Only one study, from
a historical population in Quebec, explored the effect of grand-maternal involvement on prenatal
health (Beise 2005). It found that the involvement of grandmothers (maternal and paternal) was
associated with survival during the first month of life. Assuming that mortality in that month is
primarily determined by prenatal health, this may be evidence that grandmothers improved
maternal health during pregnancy, consequently lowering the chances of neonatal mortality. The
involvement of grandmothers can be expected to be especially important in a setting like
KwaZulu-Natal, where female family networks are among the most stable sources of support
(Preston-Whyte 1978).

Men's involvement and child health—Fathers and partners

Another potentially important source of support for the mother is the child's own father. Several
studies have examined the importance of fathers for child well-being. The studies focused on
child mortality report mixed evidence for paternal support. Fathers were associated with lower
under-5 mortality in historical Québéc (Beise 2005) and lower under-10 mortality in modern-day
India (Leonetti et al. 2005). A review of the literature reports that of the 15 statistically valid
studies examining the effect of fathers on child survival, 7 found positive associations, 1 a
negative association, and 8 found no associations (Sear and Mace 2008).

In South Africa, access to fathers has been shown to be beneficial in other domains, such as
education and emotional well-being (Johnson 1996; Engle and Breaux 1998; Mboya and
Nesengani 1999; Morrell et al. 2003; Richter 2006). Drawing on ethnographic research in our
study area, Montgomery et al. (2006) described men's positive involvement in households
affected by HIV and AIDS, including caring for children, providing financial support, and
participating in household maintenance.

There is some evidence from Europe and the USA that a mother's access to the child's father, or
more generally a partner, is associated with higher birth weight. The children of married parents
tend to be heavier at birth (Miller 1991; Manderbacka et al. 1992; Reichman and Pagnini 1997).
However, being unmarried is not necessarily either detrimental or a marker for risk: the
newborns of mothers in long-term non-marital relationships have often been found to be at no
greater risk of low birth weight than the newborns of married women (Manderbacka et al. 1992).
On the other hand, it is not known to what extent findings from the USA and Europe are
applicable in a setting like South Africa, given the differences in household and partnering
arrangements. There is evidence from qualitative studies in South Africa that men's contributions
are limited by economic circumstances and class divisions, with men who are unemployed,
struggling to raise bride-wealth money, or of lower standing in the community, facing both
financial constraints and obstacles from family and community in their attempts to contribute to
their children's care (Mkhize 2006).

There is some debate, both in the African and Western literature, about whether the term ‘father’
should be restricted to a child's biological father, or should include other men acting as fathers,
such as the mother's partner or other relatives and described in the literature as ‘social fathers’
(Engle and Breaux 1998; Morrell et al. 2003; Richter 2006). However, there has been little
research on the involvement of social fathers, or on the effect of their involvement in child health
in less developed countries (Hosegood and Madhavan 2010). In rural KwaZulu-Natal, where
marriage rates are low and a large proportion of young married couples do not reside together
(Hosegood et al. 2009), the mother's marital status may not be an adequate indicator of her
partnership status, nor be an appropriate substitute for the support she might expect from a male
partner. A study of the Xhosa population in South Africa found that resident biological fathers
contributed the most to children in terms of time and money, but that, by some measures,
resident stepfathers were more involved than non-resident biological fathers (Anderson et al.
1999).

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Study setting
The study population comprised approximately 90,000 members of 11,000 households residing
in northern KwaZulu-Natal, South Africa (Tanser et al. 2007). The area includes within its
boundaries a township, rapidly expanding settlements around the township, major roads, and
rural areas. Most of the people living in the study area are Zulu speakers (Hall 1984; Monteiro-
Ferreira 2005).

Zulu-speaking communities have traditionally placed an ‘extreme emphasis on patrilineal

principle’ (Hammond-Tooke 2008) with the wife moving into the husband's homestead after the
payment of bride-wealth but living in her own hut there with her children (Laband 1997) Thus,
new mothers were largely isolated from natal kin and social contacts, while not being fully
integrated with the husband's kin (Ngubane 1976). While this way of life still exists, family-
formation patterns have been changing (Russell 2003). Declines in marriage have been noted
since the mid-twentieth century (Gluckman 1950), together with the rise of female-linked
families from which men are not absent but in which the enduring and important social ties are
between the women (Preston-Whyte 1978). In 2001, less than a quarter of adults aged 18–59
years in our study population were married, and among couples one-third lived apart (Hosegood
et al. 2009). Marriage rates are exceptionally low and have continued to decline in KwaZulu-
Natal and South Africa as a whole, as a result, at least in part, of the history of apartheid-era
economic, political, and social policies, together with continuing labour migration and limited
employment opportunities (Preston-Whyte 1993).

Owing to high unemployment, estimated at 22 per cent in 2001 (Case and Ardington 2004), and
as a legacy of apartheid, labour migration was common, with almost 40 per cent of adult men
and women residing outside the study area but still maintaining membership in households there
(Hosegood et al. 2004). Though the average household had almost nine members, only about six
were in residence at the same time. Family members still provided support for each other, with
remittances being among the most important source of income (Tanser et al. 2000) and children
receiving care and resources from a number of relatives (Hill et al. 2008).

In the early 2000s, most households with children were headed by an adult aged 18–59 (70 per
cent) and about 40 per cent of children lived in a household headed by a parent, usually the
father (32 per cent) (Hill et al. 2008). Because of low marriage rates, union instability, and
traditions of collective childrearing, only about 27 per cent of children with two surviving
parents resided with both parents (Hosegood et al. 2009). A third of children lived in a household
headed by a grandparent, with almost half of these headed by a grandmother. Both fathers and
grandmothers were important sources of support for children. Among children aged under 18
years, 18 per cent received their day-to-day care from a grandmother. While the father was not
likely to be reported as the primary care provider, fathers did provide for other needs, such as
school fees; fathers paid school fees for 47 per cent and grandmothers for 8 per cent of school
children (Hill et al. 2008).

Familes are affected by the very severe HIV epidemic. HIV prevalence in the study area was 27
per cent among women aged 15–49 years, and 14 per cent among men aged 15–54 in 2003/2004
(Welz et al. 2007). Twenty-one per cent of households experienced at least one adult death
between January 2000 and October 2002 (Hosegood et al. 2004) and many households
experienced multiple AIDS deaths (Hosegood et al. 2007). Adult mortality adversely affects
household resources in this population, not only through lost income but also through the
increased expenditures imposed by illness and funerals (Case et al. 2008).
Access to drinking water, sanitation, and electricity varied considerably across the study area. In
2001, half of the households had electricity and 13 per cent had access to piped water (Muhwava
2008). Although the area is largely rural, most households depended on wage income and State
grants (Case and Ardington 2004). In 2001, the population was served by one hospital, 11 fixed
clinics, and 31 mobile clinics, all offering family planning, antenatal care, and child
immunization (Tanser et al. 2001). Almost half the mothers in this study (44 per cent) reported at
least one antenatal care visit. Neonatal mortality among children born in 2000–02 was 43 per
1,000.

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Data and methods

Data

We used data from the Africa Centre Demographic Information System (ACDIS), maintained by
the Africa Centre for Health & Population Studies (http://www.africacentre.ac.za/). ACDIS has
been described elsewhere (Hosegood and Timaeus 2005; Tanser et al. 2007). During bi-annual
visits, detailed demographic and health data are collected on all resident and non-resident
members of households in the Umkhanyakude district of KwaZulu-Natal. Household
membership is distinguished from residence in the homestead. In this report, when we refer to
household and homestead we are referring to the household (group of individuals) and
homestead (compound) with which an individual was most closely associated by membership
and residence at the time of the child's birth.

At each household visit, information is collected about all current and recently ended
pregnancies. For live births, information about birth weight and other health indicators is
recorded from the clinic Road-to-Health card if available or from recall by a parent or a care-
giver.

Our sample consisted of 3,993 children born between 2000 and 2003. The following were
excluded: (i) multiple births, which have different patterns of birth weight (Garite et al. 2004),
(ii) children whose mothers were not resident in the study area at the time of the birth, because
no information about family and household exposures at their residence outside the surveillance
area was available from ACDIS, and (iii) children for whom valid information on birth weight
was not available. Our sample represented about half of all births to resident women during the
period. Information on birth weight was missing for 4,404 births, including 148 cases of
biologically impossible birth weights that were re-coded to ‘missing’. An examination of
potential selection bias showed that children from the wealthiest households, those who would
survive infancy, and those whose mothers were younger or married were more likely to be
included. The main reasons for birth weight not being available is that the information was not
recorded on the health card, the card was not available, or the informant did not know the birth
weight. This was often the case if the mother did not deliver with an attendant or did not take the
newborn to a clinic soon after the birth. We found that the likelihood of birth weight being
recorded was associated with the proximity of a clinic or hospital and the mother's use of
antenatal care. Sensitivity analyses showed that the results were robust to different specifications
and to estimation with a selection correction. Additionally, the observed distribution of birth
weights is similar to that reported by a clinic-based study with more complete data from the same
population (Rollins et al. 2007).

Measuring access to family support

The first time a child or adult is registered by ACDIS, information is collected on his or her
biological parents, including their survival status, household membership and residency, and
whether the parent has also been registered in ACDIS. Where parents are members of the same
household as their child, their ACDIS records are linked together. Parents’ survival status is also
recorded for each child at routine visits. Thus even though only 30 per cent of births were linked
to a father registered in ACDIS and 60 per cent to a maternal grandmother, information on
father's and grandmother's survival and co-residence with the child's mother was available for
most children.

Using the above information, we classified the status of fathers, maternal grandmothers, and
mother's partners as follows: ‘co-resident’ if he or she was a resident of the same homestead as
the mother at the interview round closest to the child's birth; ‘residing elsewhere’ if he or she was
alive but not identified with the same homestead as the mother; and as ‘deceased’ if his or her
death had been directly or indirectly reported in ACDIS. In addition, we combined information
on the mother's partnership status (married, no partner, etc.) with the partner's (if applicable)
household and homestead information. Thus, for non-marital partners, we distinguished between
those who were members of the same household and, presumably, subject to the obligations and
transactions entailed in membership, and those who were also co-resident and thus in frequent,
even daily contact with other members.

We also took into account access to the maternal grandfather and the paternal grandparents.
Where mothers were not members of the same households as these relatives no additional
information was available about the characteristics of the grandparent in ACDIS. Furthermore, if
a child's record was not linked to that of the father, we could not link to the father's regular
updates about his parents’ survival, and therefore would not have data on those who had died.
Consequently, other grandparents could be classified only as ‘co-resident’ or ‘not co-residing’,
which meant assuming that a grandfather or paternal grandmother could not provide substantial
help to the mother unless he or she resided in the same homestead.

Other social and economic characteristics

One of the challenges of understanding the effects of social support is that it is intertwined with
other characteristics (Portes 2000), such as social and economic status. Studies from the USA
have shown that low socio-economic status is associated with risk of low birth weight (Rutter
and Quine 1990; Parker et al. 1994; Rini et al. 1999). This may be because wealthier households
can provide a healthier environment, including better nutrition and less poverty-induced stress
for the mother. We used information on the resources owned by the household in 2000/2001, at
the time of or shortly before the pregnancy, asindicators of household wealth (house construction
materials, household amenities, ownership of commodities) and ranked households into quintiles
according to their relative long-term wealth, using principal components analysis (PCA)
(following Dunteman 1989; Filmer and Pritchett 2001). Mother's level of education was included
as it has been shown to correlate with child health, including birth weight (Warner 1998; Rini et
al. 1999; Feldman et al. 2000). A variable that had not been previously explored but that seemed
likely to be important in a highly mobile population was the frequency of periods away from the
homestead. This was seen as an indicator of the mother's exposure to the household environment,
access to family support, and also indicative of access to sources of income. Because negative
financial shocks and health shocks may cause maternal stress, which may affect foetal
development (Hoffman and Hatch 1996), we included indicators of whether the household had
recently experienced a major financial shock (job loss or major loss of property owing to theft,
fire, or flood) and an indicator of whether the household had reported recent experience of a
major health shock (death or serious illness).

Statistical methods

The first set of analyses focused on the association between birth weight and the survival and
residency status of the child's biological father and maternal grandmother. We used ordinary
least squares (OLS) regressions with robust standard errors. The dependent variable was weight
in grams, measured as a continuous variable:

(1)

On the right-hand side, categorical variables indicate the mother's access during pregnancy to her
own mother (vg) and to the child's biological father (tp), each coded as follows: deceased; alive
but not co-residing with the mother (omitted category), and co-residing with the mother at the
child's birth. In models examining the role of partnership patterns, we re-coded tp to indicate the
mother's partnership arrangement at the child's birth as follows: married to partner; co-resident
with non-marital partner who is also a household member; non-marital partner is a member of
the same household but resides elsewhere; non-marital partner neither resides with mother nor is
a member of the same household; and no partner (omitted category). In models estimating the
effects of access to the other grandparents, we re-coded vg to indicate co-residence as follows:
co-residing with the mother at the child's birth, not co-residing with the mother, including
deceased (omitted category).

We included bio-demographic variables known to affect birth weight: the mother's age at birth,
whether this was her first live birth, and the child's sex. These are denoted as Wc. Similarly, Xm
captures the socio-economic characteristics of the mother: education and whether she was
regularly away from home overnight. Yh is a vector of household characteristics, including the
wealth quintile, the indicator of any financial shocks, and the indicator of any health shocks.
Since residents in some locations, because of disease environments or lack of access to
resources, may be more prone to poor health, we included Zi, a vector of dummy variables for
each of the 24 traditional administrative units called isigodi. Finally, we included a series of
dummy variables indicating the child's year of birth, Uy, to capture secular trends in birth weight.
In additional models, we added interactions to test the importance of the family environment in
particular circumstances. We investigated whether grandchildren of grandmothers eligible for
State old-age pensions (those aged 60 years and older) had a higher birth weight than those with
younger grandmothers. To test this, we added a dummy variable indicating whether the
grandmother was of pensionable age. We also investigated whether the importance of pension
was affected by co-residence. In another test, we investigated whether access to the grandmother
was more beneficial for inexperienced (firsttime) mothers. Finally, we tested whether the role of
family environment differed by wealth status.

Because many observations did not have information on birth weight, we re-estimated all models
as Heckman selection correction models. In these, the non-selection hazard was estimated in the
first stage on all covariates used in the study plus two exclusion variables to test the effect of two
influences on whether birth weight data were obtained or retained by the family. The exclusion
variables were

i. distance to the nearest clinic or hospital, and

ii. whether the child subsequently died.

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Results
Descriptive statistics from the interview round closest to the child's birth are shown in Table 1.
The average birth weight is 3,110 grams and the median is 3,100 grams, with less than 10 per
cent of the sample falling below the 2,500-gram low-birth-weight cut-off. Sixteen per cent of the
mothers co-resided with the child's father during pregnancy and 37 per cent resided with their
own mothers (these categories are not mutually exclusive). Few of the mothers co-resided with
their own fathers (12 per cent) and even fewer with their child's paternal grandmother (3 per
cent) or grandfather (1 per cent) (again, these categories are not mutually exclusive). Seventeen
per cent of the mothers were married at the time of this child's birth, while 22 per cent had no
partner. Over half of the women were under 25 years old, had a high school education, and for
slightly less than half of them, the index child was their first live birth.

Table 1
Characteristics of children and their families used for a study of the relationship between birth
weight and access to father and grandparents, KwaZulu-Natal, South Africa, 2000–2003

As shown in Table 2, all bio-demographic variables exhibit significant associations with birth
weight. Boys are about 99 grams heavier than girls at birth, first-born children are about 100
grams lighter than other infants, and children born to older mothers are heavier than children
born to teenagers or mothers in their early 20s.
Table 2
Regression of child's birth weight in grams on father's and grandmother's co-residence with
mother; coefficients estimated from ordinary least squares (OLS) regression, KwaZulu-Natal,
South Africa, 2000–2003

Birth weight and access to the biological father and partnerships

Table 2 presents results for the association between the biological father's co-residence with the
mother, his survival, and the child's birth weight. The co-residence of the biological parents has a
significant positive association with birth weight in bivariate estimates. This association is
reduced but remains significant in the adjusted model. After controlling for the other explanatory
variables, infants whose fathers and mothers co-resided when the infant was born are on average
59 grams heavier at birth than infants whose fathers lived elsewhere. It is the father'sresidence in
the same homestead, rather than his survival status that seems to matter. In fact, infants born to
women who did not reside with the father have a birth weight similar to that of infants whose
fathers had died. Further, in Heckman models that adjust for selection, children whose fathers
were deceased were born on average heavier than those whose fathers resided elsewhere.

The ACDIS data allow us to examine in greater depth the association between birth weight and
the mother's access to a partner. In the models presented in Table 3, we include information
about the mother's partnership during pregnancy. All combinations of categories were tested for
significant differences from the omitted category (no partner) and from each other. Infants born
to women who had no partner at the time of the birth are significantly lighter than infants born to
married women or to women with a non-marital partner. The strength of associations is reduced
by the inclusion of other explanatory variables in the models, but remains large and significant
across specifications. Infants born to mothers who were married at the time of birth are the
heaviest. They are 180 grams heavier than infants born to mothers without partners. The next
heaviest are infants born to women whose non-marital partner was a member of the same
household and who was co-residing with the mother (122 grams heavier thaninfants of mothers
without partners). Furthermore, infants born to mothers who had a partner, whether or not the
partner was a member of the same household, are also significantly heavier, by 84–107 grams,
than infants born to mothers without partners. These results suggest that mothers greatly benefit
from having a regular partner, especially if the relationship is marital, and that joint household
membership and co-residence can be beneficial even if the relationship is not marital.
Table 3
Regression of child's birth weight in grams on mother's partnership arrangement; coefficients
estimated from ordinary least squares (OLS) regression, KwaZulu-Natal, South Africa, 2000–
2003

In post-estimation tests of linear combinations of estimators, the following partnership

arrangements are significantly different from each other at the 0.05 level or lower in multivariate
models: married vs. partner who is a household member but not co-residing; and married vs.
partner who is neither co-residing nor a member of the same household. In both bivariate and
adjusted models, all non-marital partnerships are associated with a significantly higher birth
weight than those with no partner. If they are not co-resident, non-marital partnerships are
associated with a lower birth weight than for married couples, but birth weight does not differ
between coresident non-marital partnerships and married couples in adjusted models.

Because the potential benefits of support may vary by wealth, we also tested for interactions
between mother's partnership status and household wealth. No significant differences were found
by wealth quintile or among those living in poorer-than-average households (see Table A2).

Birth weight and access to the maternal grandmother and other grandparents

Table 2 presents the unadjusted and adjusted associations between birth weight and the presence
of the maternal grandmother. In bivariate estimates, infants whose maternal grandmothers had
died are lighter at birth than those whose maternal grandmothers were still alive but living
elsewhere. Newborns whose grandmothers were living in the same homestead as the mother are
also significantly lighter than infants whose grandmothers were alive but not co-residing with the
mother. However, in the fully adjusted models, the association between grandmother's co-
residence and birth weight is reduced substantially and is no longer significant. In the adjusted
model, infants with a surviving maternal grandmother are heavier by an average of 46 grams
than those whose maternal grandmothers had died, reaching marginal significance. In the
Heckman model, the disadvantage of those with deceased grandmothers is greater (63 grams)
and significant at the 0.05 level.

We expected that access to a grandmother with a pension might provide the mother with
greaterfinancial support that could be used to purchase better nutrition and care, and therefore be
associated with higher birth weight. In fact we find that the coefficient for the grandmother's
pension eligibility is not statistically significant and the inclusion of this variable does not
materially alter the results for grandmother's co-residence and survival. Since co-residence may
affect transfers, we also tested for interactions between grandmother's pension eligibility and co-
residence with the mother, but the interaction was also not statistically significant. We also
examined whether the presence of the grandmother confers greater benefits for first-time
mothers, for mothers who spend time away from home regularly, and for mothers living in
households that have recently experienced economic shocks. We did not find evidence that co-
residence with the grandmother serves as a buffer in these circumstances (see Table A2). Finally,
we did not find evidence that the grandmother can substitute for the father. The coefficients for
father's survival status and co-residence are not materially altered by the inclusion of information
about the grandmother's co-residence and survival. This suggests that the grandmother and the
father have independent effects on birth weight.

Table 4 shows bivariate and adjusted associations between the mother's co-residence with each
of the child's four grandparents and the child's birth weight. In bivariate results, mothers who
resided with their own parents during pregnancy have significantly lighter newborns, while the
newborns are significantly heavier for mothers who resided with the child's paternal
grandparents. All of these associations become non-significant when we control for the mother's
partnerships and are reduced even further with the inclusion of the other variables. One possible
exception is co-residence with the paternal grandfather, which remains significantly associated
with birth weight in the Heckman model though not in the OLS model. These patterns indicate
that children whose mothers live with the maternal grandparents are born relatively light while
those whose mothers live with paternal grandparents are born relatively heavy; however, these
results do not necessarily reflect the effects of living with different categories of grandparent.
Rather, it is likely that mothers who live with their partners’ parents are in longer-term
relationships and wealthier households, and that it is partnership, and especially marital status,
that affects birth weight. Specifically, 76 per cent of mothers living with the paternal grandfather
and 73 per cent of mothers living with the paternal grandmother are either married or have a co-
residing partner, compared with less than 2 per cent of those living with maternal grandparents.

Table 4
Regression of child's birth weight in grams on each grandparent's co-residence with mother;
coefficients estimated from ordinary least squares (OLS) regression, KwaZulu-Natal, South
Africa, 2000–2003

Birth weight and other social and economic characteristics

Birth weight is significantly associated with the social and economic environment of mothers
during pregnancy, as shown in Table 2. Infants born to mothers in wealthier households are
heavier than those in poorer households, though the greatest improvements in birth weight are
associated with being in the next-to-poorest rather than the poorest quintile, with no significant
increases among wealthier quintiles. Even after controlling for wealth, household-level economic
shocks are associated with lower birth weight: infants born in households experiencing an
economic shock during pregnancy are about 44 grams lighter than other infants, although this
association is only marginally significant. However, birth weight is not significantly associated
with household health shocks or with mother's education. Mothers who are regularly away from
their homestead tend to give birth to lighter infants, although the association is not statistically
significant.

By comparing the results from bivariate results and models with economic controls, we can
assess the extent to which the relationships between access to family and birth weight operate
through socioeconomic circumstances. For example, do fathers and grandmothers appear to be
important simply because expectant mothers who co-reside with them are members of wealthier
households? The inclusion of economic variables, such as wealth ranking, reduces the negative
association between co-residence with the maternal grandmother and birth weight, indicating that
these negative associations are partly explained by poverty and economic shocks. However, the
positive associations between the mother's access to a partner and birth weight remain large and
significant, indicating that the importance of fathers for birth weight is not simply explained by
observed socio-economic characteristics, but that there may be additional benefits conferred by
established and especially co-resident partnerships.

Go to:

Discussion
Social support is widely believed to affect health, with the family being among its most
important sources. In our study, we examined associations between the mother's access to a
partner and to her child's grandparents and the child's weight at birth in rural South Africa. We
found that women whose own mothers are still alive gave birth to heavier newborns than women
whose mothers are deceased. At the same time, no additional benefits from co-residence with the
mother were detected. Nor was co-residence with the paternal grandmother or the grandfathers
associated with birth weight after controlling for access to a male partner. Thus, the proposition
that co-residence is a primary mechanism through which mothers receive assistance from
grandparents is not supported. On the other hand, at least in the case of the maternal
grandmother, it seems that support may be provided by grandmothers who reside elsewhere.

Previous studies have found some benefits from grandmother's pension eligibility for
grandchildren's access to food and education and for their growth (Case and Deaton 1998; Duflo
2003). We found no evidence that the benefit of an old-age pension extends to grandchildren's
prenatal growth, since grandmother's pension eligibility did not correlate significantly with birth
weight, nor did it substantially change the correlations between birth weight and the
grandmother's presence. It may be that the support received from grandmothers is not strictly
financial, but involves in-kind assistance or protection against violence or other threats. The
potential benefits of pensions may be confounded by the fact that care is not necessarily
unidirectional from older mother to adult daughter: older grandmothers may require substantial
care and resources from their daughters, especially if they co-reside. We did not find that the
presence of the maternal grandmother could substitute for a non-resident father.
Father's co-residence with the mother was significantly and positively associated with the infant's
birth weight. However, our results suggest that studies that focus only on fathers or on marital
status can miss important distinctions in relationships and the support these relationships provide
for child health. A strength of the method we adopted was the ability to identify the type of
relationship that existed between the mother and her partner in more detail than in previous
studies. We were able to establish patterns of co-residence in the same homestead and
membership in the same household. Birth weight was highest among infants born to married
women and lowest among those born to women with no regular partner, even after adjusting for
maternal and household characteristics. Nonetheless, marriage is not the only type of partnership
associated with birth weight. A mother appeared to benefit from being a member of the same
household as her non-marital partner and especially from residing in the same homestead. Co-
residence was independently associated with higher birth weight, suggesting that co-habitation
may provide additional benefits beyond financial support. This emphasizes the value of family
contact for migrant workers, for example, by the expansion of family housing in places where
employment opportunities attract labour migrants.

The norms and circumstances experienced by families living in KwaZulu-Natal are changing.
However, patrilocal traditions remain influential, as evidenced by the finding that a mother's co-
residence with the child's father, especially if she is married to him, is associated with better
health for her baby while co-residence with her parents is not. By custom, the foetus is thought to
belong to the father's lineage and the mother is only a channel through which the child enters the
world (Ngubane 1976). From this perspective, it would be expected that the father's kin would
have a vested interest in ensuring that the mother lived in a healthy and protected environment.
At the same time, because pregnancy is traditionally a time when a woman is expected to limit
social exposure (Ngubane 1976), she may have less contact with her native kin, who, in any case
would not have as much invested in the pregnancy. In addition, the mother may feel the stress of
her marginalization more keenly in the homestead of her own parents, and perhaps welcome the
comfort of the new bond with her partner and his family if co-residing with them. Previous
studies have found great concern among young women in sub-Saharan Africa about becoming
pregnant when not certain of the identity of the father (Nshindano and Maharaj 2008). It may be
that it is only when the relationship has been formalized through marriage or co-residence that a
woman can feel confident that the legitimacy of her unborn child is confirmed.

Socio-economic features of the homestead environment, specifically assets and financial shocks,
were significantly associated with birth weight. The fact that birth weight is more strongly
associated with economic shocks than with health shocks may indicate that the effects of shocks
are experienced more strongly through reductions in resources than through emotional stress.

Though the results reported above are robust to alternative specifications and to the inclusion of
additional variables, we cannot conclude that the relationships between access to family
members and birth weight are causal, since residual confounding can arise from characteristics
that have not beencaptured and from measurement error in the variables that were included. For
example, the HIV status of the mother may be associated with access to family support and to
weight at birth, but we could not take it into account because HIV testing in the ACDIS had not
begun when many of the children were born.
An important concern is the possibility of a bias in the sample because birth weight data were not
available for almost half the births. If the effects of grandmothers and partners were the same for
those with missing as for those with known birth weight, no bias would have been introduced.
However, if family support was more important for health at birth among children whose birth
weights were unknown, then our estimates of the relationship between family support and birth
weight would have been biased downwards. For example, given that the presence of fathers and
grandmothers is known to correlate with probability of survival, and that data were more likely
to be missing for children who subsequently died, cases with surviving children were more likely
to be represented in our study. Again, our findings would under-estimate the importance of
fathers and grandparents because the full effect of not having access to them would not have
been observed. A related concern is that family support may have been more important among
the poorest households. While we did not find significant interactions between socio-economic
status and access to grandparental and partner support, it is possible that these patterns were
different among those who were not included in our sample owing to missing data on birth
weight. If family was more important among the poorest, with in-kind support substituting for
other resources, and the poorest were more likely to be excluded from our sample owing to
missing information, again our results would be under-estimates of the importance of
grandparental and partner support. To correct for selection caused by missing information on
birth weight, we re-estimated all models as Heckman selection correction models. Most results
were not significantly different from the OLS results.

Another concern is that previous research has shown that there may be errors in the reporting of
birth-weight data in surveys (Boerma et al. 1996; Robles and Goldman 1999). We estimated
alternative models with birth weight divided into three categories: low, average, and high. The
results (not shown) were consistent with those reported above.

Because respondents were not asked about the support they received from or gave to others, we
were unable to take into account the extent and type of contact with and assistance from partners
and the child's grandparents.

The results of our analyses illustrate the importance of adequately characterizing partnership
arrangements, especially in settings where marriage is not universal and non-marital childbearing
is common. They also highlight the fact that relationships may be supportive in some
circumstances but not in others. For example, while co-residence with a partner appears to be
beneficial, co-residence with a grandparent does not. Conversely, a grandmother residing
elsewhere seems to be beneficial, while a father residing elsewhere does not. An improved
understanding of the ways in which family members provide support can inform policies to
promote and enhance positive family support to mothers and children.

There is mounting evidence that social support is of benefit to health, but what it is about social
support that is beneficial remains unclear. It may be that support networks actually provide care,
information, and goods that are instrumental in health promotion. There may also be
psychosomatic benefits to receiving and giving support that can improve health. Whether in
KwaZulu-Natal or elsewhere, the family is the primary source of social support. We have shown
that the benefits of the family environment may extend not only to the individual, but to the well-
being of the next generation from the very beginning. Family arrangements and the ways in
which different types of support are provided within families are not static in South Africa and
elsewhere. Our findings suggest that demographers’ and policy-makers’ definitions of the family
also need be flexible in order to identify and strengthen the sources of support on which mothers
rely.

Go to:

Appendix
Table A1

Regression of child's birth weight in grams on maternal grandmother's survival and residence,
and on mother's partnership arrangement: comparison of estimates from models using Heckman
selection correction and OLS regression models KwaZulu-Natal, South Africa, 2000–2003

OLS model Heckman selection model

Maternal grandmother's survival and residence
(not co-residing with mother)
Co-residing with mother 11.78 (21.35) -15.28 (23.04)
Deceased -38.00 (24.37) -51.40 (25.17)∗
Mother's partnerships (no partner)2
Married 179.60 (36.35)∗∗ 122.62 (37.98)∗∗
Partner co-resident and is a household member 121.88 (37.91)∗∗ 99.96 (39.01)∗
Partner not co-resident but is a household member 107.21 (36.86)∗∗ 89.60 (39.46)∗
Partner not co-resident and not a household member 83.98 (24.28)∗∗ 86.17 (25.67)∗∗

1
In the Heckman selection correction models, the non-selection hazard is estimated in the first
stage on all covariates presented in the paper plus two exclusion variables, which are: distance to
the nearest clinic or hospital and whether the child subsequently died. These variables were
selected because they were expected to affect whether birth weight data are obtained or retained
by the family while not affecting birth weight itself. Distance to clinic predicts missing birth
weight (p = 0.032), as does whether the child subsequently died (p = 0.000).
2
The models also include: child's sex, mother's age at child's birth, parity, mother's education,
household wealth and health shocks, isigodi (traditional administrative unit) and year-of-birth
dummy variables, and dummy-variable adjustments for missing values.

Notes: Statistical significance: +p < 0.10; ∗p < 0.05; ∗∗p < 0.01.

Source: As for Table 1.

TABLE A2
Regression of child's birth weight in grams on access to family in specific circumstances,
coefficients estimated from ordinary least squares (OLS) regression with interaction terms,
KwaZulu-Natal, South Africa, 2000–2003

Marriage Pension and First birth Travel and Economic

and co- and co- co- shocks and
poverty1 residence2
residence2 residence2 co-residence2
Maternal grandmother's
survival and residence (not
co-residing with mother)
10.90 –12.47 28.83 – 7.28
Co-residing with mother
(21.32) (21.78) (27.93) (21.32)
– 37.60 –43.32 – 53.74 –41.19
Deceased
(24.39) (24.96) + (29.78) + (25.21)
Maternal grandmother 10.64
pension-eligible (31.96)
Bio-demographic
characteristics
– 74.62 –100.00 – 74.43 – 99.74 -104.24
First-born child
(22.77)∗∗ (22.11)∗∗ (30.09)∗ (22.12)∗∗ (23.46)∗∗
Social and economic
characteristics
194.14
Mother married
(47.15)∗∗
Mother spends time away – 24.03 –34.78 – 37.18 – 18.67
-31.95 (28.81)
regularly (26.88) (26.80) (26.77) (46.60)
Household poorer than – 69.84
mean (38.17) +
Experienced economic –41.34 –45.74 – 47.15 – 45.56 - 43.55
shock (24.07) + (24.17) + (24.15) + (24.14) + (34.74)
Interactions
Married × Household – 26.91
poorer than mean (54.91)
Maternal grandmother co-
12.78
residing with mother ×
(44.86)
Pension-eligible
Maternal grandmother co-
– 67.88
residing with mother ×
(37.64) +
First-born child
Maternal grandmother co-
residing with mother × –17.19
Mother spends time away (58.21)
regularly
 Marriage Pension and First birth Travel and Economic
and co- and co- co- shocks and
poverty1 residence2
residence2 residence2 co-residence2
Maternal grandmother co-
residing with mother × - 37.82
Household experienced (49.67)
economic shock
3,155.16 3,148.50 3,136.95 3,146.28 3,170.22
Constant
(54.90)∗∗ (49.23)∗∗ (49.76)∗∗ (49.38)∗∗ (53.94)∗∗
Observations 3,993 3,993 3,993 3,993 3,993
R2 0.06 0.05 0.05 0.05 0.06

1
The model also includes: child's sex, mother's age at child's birth, parity, mother's education,
health shocks, isigodi (traditional administrative unit) and year-of-birth dummy variables, and
dummy-variable adjustments for missing values.
2
The models also include: child's sex, mother's age at child's birth, parity, mother's education,
household wealth and health shocks, father's survival and residence, isigodi (traditional
administrative unit) and year-of-birth dummy variables, and dummy-variable adjustments for
missing values.

Notes: Robust standard errors in parentheses. Statistical significance: + p < 0.10; ∗p < 0.05; ∗∗p
< 0.01.

Source: As for Table 1.

Go to:

Notes
1. Solveig Argeseanu Cunningham is at the Hubert Department of Global Health, Emory
University, 1518 Clifton Road NE, Atlanta, GA 30322, USA. E-mail:
[email protected]. Irma T. Elo is at the University of Pennsylvania; Kobus Herbst is at
the Africa Centre for Health & Population Studies, University of KwaZulu-Natal;
Victoria Hosegood is at the London School of Hygiene & Tropical Medicine, and the
Africa Centre for Health & Population Studies, University of KwaZulu-Natal.
2. This study was partially supported by the National Institute of Child Health Department
(NICHD) training grant T 32 HD 007242 awarded to the University of Pennsylvania. The
Welcome Trust in the UK provided funding support through grants to the Africa Centre
Demographic and HIV Surveillance (#GRO82384/Z/07/Z) and Victoria Hosegood
(#WT082599MA). We thank the ACDIS field and data centre staff and the Africa Centre
for Health & Population Studies. This paper benefited from the comments of Christopher
Cunningham, Marie-Louise Newell, Jere Behrman, Susan Watkins, and Etienne Van De
Walle.
Go to:

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