The ghost of mortality: child loss and parity in Malawi, 1992–2024

Child loss remains an important factor associated with fertility behaviour in high mortality settings, but its association with parity across the reproductive life course and over time remains unclear. Malawi provides an important setting to examine these patterns given substantial declines in under-five mortality over recent decades. Pooled data from six Malawi Demographic and Health Surveys (1992–2024) were analysed to examine the association between under-five deaths and total children ever born. Survey-weighted Poisson regression models assessed overall associations, age-specific heterogeneity, and changes across historical periods. Predictive margins were used to describe differences in parity by child loss category. Complete birth histories were additionally examined to assess subsequent births following child loss. Each additional under-five death was associated with a 13.9% higher incidence rate of parity (IRR = 1.139, p < 0.001). Women with one loss had higher parity incidence than women with no loss (IRR = 1.788), while those with two or more losses had substantially higher parity (IRR = 2.637). Age-specific models showed stronger relative differences among younger women, while absolute differences increased with age. The association between child loss and parity persisted across survey periods, although relative differences were smaller in recent years. Among women experiencing child loss, 85.5% subsequently had another birth. Child loss remains associated with higher parity in Malawi despite improvements in child survival. The relationship is observed across age groups and time periods, showing the need for continued access to family planning and support after child loss.