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children, particularly those with severe acute malnutrition, have a higher risk
of death from common childhood illness; nutrition-related factors contribute to
about 45% of deaths in children under 5 years of age. Several studies diagnose
Malaria, Diarrhea and Pneumonia preventable causes of dyeing millions of
under-5 children every year. Almost half of the children are dying due to acute
malnutrition e.g. mother unawareness about her pregnancy, nutrition
requirement, careless attitude towards pregnancy due to multiple birth, birth
interval and poor sanitation and health facilities. Globally major reason for
under-5 child and neonatal child mortality can be explained by large
inequalities between countries. on the country level, under-5 child mortality
ranges from 133/1000 live birth to a low level 2/1000 live births.  Almost 80 percent
of under-5 children is represented by two regions i.e  Sub-Sahara Africa and Southern Asia specially
India, Nigeria, Pakistan, the Democratic Republic of the Congo, Ethiopia and
China. Gender discrepancies among under-5 child mortality are evident in many
regions such as southern Asia and western Asia, gradually declining. The ratio
for Neonatal death is 19/1000 live births during 2016, 1 million child dying on
the day of birth.

reduce under-5 child mortality and well-being of the children United Nation set
some goals like Millennium development goal 2/3 between 1990-2015 and after
Millennium development goals now Sustainable development goal to reduce
neonatal mortality 12/1000 live births and under-5 25/1000 live births in 2030.
Globally during past two decades shows a declining trend in reducing child
mortality 93/1000 live births in 1990 to 41/1000 live birth in 2016.

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is one of the country who already achieved Millennium development goal 4,
48/1000 live births over the past two decades 133 to 46 under-5 deaths per 1000
live births and 52 to 28 neonatal and 87 to 38 in infant live deaths during the
period of 1989-2014. Proportion of declining neonatal deaths comparatively
infant and under-5 are less declining.

there are different socioeconomic demographic characteristics, which play a
great role in higher child mortality in any stage less developed areas. These
variables include mother education level having an inverse relation with child
mortality. Latest statistics from BDHS -2014 shows that mother who never
attended school are almost twice under-5 child mortality in comparison to that
mother having secondary or higher education. All BDHS data of different birth
cohort from 1988-2014 showing the same sex ratio of child mortality higher for
girls than boys except neonatal, same pattern has also observed in other South
Asian countries.            

Maternal fertility behavior and high-risk
child mortality is a big debate found from numerous previous literature.
Probability of child dying under-5 is higher in young females aged less than 18
or too old women aged more than 34 is found to be higher. The nutritional
factor is very important factor in this regard. The unique example of
restricted maternal nutrition are Dutch famine during World War II. Those women
they have an utero exposure during this period, child will be at higher risk of
diabetes, obesity and cardiovascular disease in later life outcome. Women who
are underweight and malnutrition prior to conception with BMI less than 18.5
have a higher risk to child and preterm delivery (Hauger et al. 2008). Several
studies found that over exercising during utero exposure and restricted
maternal nutrition “Progorexia” have several impact in later life. Efficient
diet plan to fulfill the utero requirement of nutrient-dense food comparatively
just to eat empty-calorie food. In 2002 the institute of Medicine (IOM) revised
the Dietary Reference Intake (DRI) during pregnancy, for normal utero-mother no
need of extra caloric intake for the first trimester, in  a second trimester need to meet the caloric
requirement of 340 kcal/day, and add 452 kcal/day for the third trimester
(Panel of Macronutrients, Institute of Medicine, 2002).

another study Butte et al. (1994) outlines the additional energy intake during
pregnancy by trimester; in first trimester, the underweight women should
increase energy intake by an additional 150 kcal/day, in second 200kcal/day and
in third 300kcal/day. The more accurate way to monitor mother weight gain
during pregnancy. Healthy fetal development is dependent on the availability of
adequate protein which provides the basic building blocks necessary for
formation of enzymes, antibodies, muscles, and collagen. Lipids and fats,
essential fatty acids,  choline, Fiber,
carbohydrates, vitamin A and D, calcium, B vitamins, Vitamins B12, Folate,
Iron, Magnesium, Zinc, IodineEarly gestation period or first few week of utero
is crucial for a baby for the efficient programming of embryonic organ development
in addition to any restricted maternal malnutrition or skipping meal, selective
food selection to eat and fewer caloric intake may main cause of less formation
of cell as per normal and later outcome in a form of low birth weight infant,
several miscarriages, and birth defects in later life. Second trimester or
middle part of the gestation is important for faster embryonic growth, the
organ of the baby start functioning and you can feel the movement of your baby.
Garofalo, G. et al, (2017) evaluate the high maternal pregnancy termination
outcome during first and second trimester by analyzing 844 pregnant women in a
retrospective study from January 2007 to December 2011. They found a
significant risk factor of uterine surgery during second trimester pregnancy
termination and the main cause of uterine surgery is a caesarean section during
previous birth.


Given the importance of
nutritional needs of pregnanta mothers and its impact on the child health and
survival chances, Ramadan is a unique experiment to observe such impacts. Ramadan
is observed as a month of fasting by Muslims. The length of fasting depends on
season, where minimum duration ranges from 8 hours to maximum 20 hours (during
dawn to dusk) depending on the geographical location of the different
countries.  The menstruating women,
pregnant women and lactating women are exempted from fasting. Seasonality is a
potential confounding factor because Ramadan follow a lunar calendar, based on
appearance and disappearance of the moon has 354 days, moves forward roughly by
11 days each year according to Gregorian (Western) calendar. After 32 years
Ramadan, complete one full Western circle.  

focus of the present study is the early-life exposure and restricted timing of
maternal nutrition (Ramadan fasting) on fetal development link with child
mortality. Three out of four utero overlap with Ramadan, approximately 1.8
billion Muslims 24% share of the world population alive today. Prentice et
al., 1983 said ‘acceleration starvation’ occur when utero overlapped with
Ramadan with sharp decline of maternal glucose, metabolic changes and
neurological development. For many of Medical studies regarding fetus health
highly recommended that never skipping meal during pregnancy to avoid long-term
health impacts.

Almond and Mozmudar, 2011 are the first one who used large-sample
microdata on Muslims in Iraq and Uganda by comparing the birthdays of many
years overlap with Ramadan timings and estimate the reduced form effect and ITT
(intent to treat) effect with relay on decision, whether they fast or not to
fast. They found largely 20% disability in adults when Ramadan overlap with
early pregnancy in Iraq and Uganda and lower birth weight in natality data from
Michigan. Many studies also said as like poor prenatal environment lead to fewer
male offspring followed by Almond and Mozmudar, 2011 when early pregnancy
overlapped with Ramadan during peak period of daylight fasting hours 12% lower
male birth.

The identification strategy address seasonality in birth outcomes,
a potential confounder due to the forward movement of roughly 11 days each year
as per Gregorian (Western) calendar. To disentangle the effect of seasonality,
the study uses a  large sample with 28
birth cohorts and “difference in differences” to remove any seasonal effects
experienced by the untreated group of non-Muslims.

2 of the study presents the previous epidemiological work on Ramadan and health
and child mortality. Section 3 briefly describes Bangladesh Demographic and
Health Survey (BDHS), ITT measures and econometric model. Section 4 present
analysis tables for both treatment group (Muslims) and control group
(Non-Muslims) and DID results and brief description of my analysis and
robustness checks. The final section cover concluding remarks, implications of
my research as per policy perspectives.


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