MATERNAL EDUCATION, CHILDHOOD MORBIDITY AND UNDER FIVE MORTALITIES IN NIGERIA

ABSTRACT

This study examines the effect of maternal education on childhood morbidity and under-five mortalities  in  Nigeria using the  Nigeria  Demographic  and  Health  Survey (NDHS),  2013. Empirically, the study employs instrumental variable probit regression (Ivprobit) model to investigate the relationship between maternal education and child health outcomes while the multinomial logit model was estimated to test the disaggregated effect of maternal education on the varying rate of under-five mortality across the six geopolitical zones in Nigeria.  The study used data at the individual level, with a total of 18, 563 observations to test the model on under-five mortality while the model on childhood morbidity and disaggregated effect of maternal education was tested at the household level with a total of 16,536 observations. The result showed that maternal education has a significantly negative relationship with under-five mortality but not with childhood morbidity. The result from the multinomial logit regression shows that mother‟s level of education and wealth status exert more significant effect on regional  disparity in  under-five  mortality in  Nigeria  more  than  religion  or  belief  system. Intuitively, maternal education can only be effective in improving child health outcomes if such education can potentially impact positively on other socio-economic variables that determine  child  health  outcomes  especially  wealth  index,  poor  childcare  attitude  and obnoxious belief systems. The study concludes that policy interventions by government to address child health vulnerability and inequality in Nigeria through maternal education should coherently improve the socio-economic characteristics of would-be mothers for it to be effective.Keywords:       Maternal       Education,       Under-five       Mortality,       Childhood       Morbidity

CHAPTER ONE INTRODUCTION

1.1.   Background to the study

Childhood morbidity and under five mortality are essential indicators for child health and well- being, often used as broad indicators of social and economic development of nations. Consequently, improvements in health outcomes for children especially those under the age of five years (0 – 5 years) are imperative element in national development agenda World Health Organization (WHO, 2010). Imperatively, considering children as agents of continuity of any country, childhood mortality or survival is not only a core indicator for child health and wellbeing but also a critical measure of socio-economic development in any country (Adetoro

& Amoo, 2014).

The United Nations Children‟s Emergency Fund (UNICEF) in its 2016 edition of the on the State of the World’s Children 2016: A fair Chance for Every Child”; stated that diminishing the prospects of survival or decent health of any child because of the circumstances around his or her birth is grossly unfair and a violation of that child‟s rights. The UNICEF in this Report reiterated that every child is born with the equal inalienable right to a healthy start in life, an education and a safe, secure childhood with all the basic opportunities that translate into a productive and prosperous adulthood. Nevertheless, around the world, “millions of children are denied their rights and deprived of the fundamental requirements they need to grow up healthy and strong, either because of their place of birth or their family of origin; because of their race, ethnicity or gender; or because they live in poverty or with a disability” (UNICEF, State of the World’s Children Report, 2016).

According to the UN Inter-agency Group for Child Mortality Estimation, (UN, IGME, 2017

Report), Sub-Saharan Africa remains the region with the highest under-five mortality rate in the world. The Report stated that in 2016, the region had an average under-five mortality rate of 79 deaths per 1,000 live births which translates to 1 child in every 13 dying before his or her fifth birthday – 15 times higher than the average ratio of 1 in 189 in high-income countries, or

20 times higher than the ratio of 1 in 250 in the region of Australia and New-Zealand. The Report highlighted that about 80 per cent of under-five deaths occur in two regions, sub- Saharan Africa and Southern Asia, with Nigeria being the second largest contributor to under – five and maternal mortality rate in the world, losing about 2,300 under-five year children and

145 women of child bearing age every single day. Every year, millions of the world‟s children under 5 years of age die, mostly from Preventable diseases such as pneumonia, diarrhoea and malaria. The Report further revealed that every day, 15,000 children die globally, mostly from Preventable causes and preventable diseases, even though the knowledge and technologies for life-saving interventions have increased over time. (UN, IGME Report, 2017).

As evidenced in Nigeria‟s National Demographic and Health Survey (NDHS Report, 2013); infant mortality rate was 75 deaths per 1,000 live births in the 2004 – 2008 survey and 69 deaths per 1,000 live births in the 2009 – 2013 survey. While under-five mortality was 157 deaths per 1,000 live births in the 2004 – 2008 survey and 128 deaths per 1,000 live births in

2009 -2013 survey. At these levels of mortality, one out of every 15 Nigerian children die before reaching age 1, while one in every eight do not survive beyond their fifth birthday (UNICEF, 2013; Morakinyo & Fagbamigbe, 2017). Acute respiratory tract infection (ARI), diarrheal diseases, and neonatal syndromes (preterm birth complications, neonatal encephalopathy, neonatal sepsis, and other neonatal disorders) accounted for 54% of the total under-five deaths in 2013.

The NDHS Report, 2013 further suggested that the prevailing rates of morbidity and under-five mortality in Nigeria could be attributed to the years or levels of education especially among women  of  childbearing  age.  Consequently,  under-five  mortality  among  children  born  to mothers with no education which was about (180 deaths per 1,000 live births); is almost twice that of children born to mothers with secondary education (91 deaths per 1,000 live births) and three times that of children born to mothers with more than secondary education (62 deaths per

1,000  live  births)  (NDHS,  2013).  This  linkage  is  traceable  to  poor  healthcare  facility utilization, malnutrition in children, low levels of vaccination coverage, unsafe water, poor sanitation and hygiene; which are likely not unconnected to low levels of maternal education (Carvajal–Aguirre et al, 2017).

Observably, all indicators of child health outcomes vary with the levels of women education and other socioeconomic characteristics that education could influence. In the Multiple Indicators Clusters Survey (MICS, 2016/17), findings indicate that incidences of childhood morbidity decrease as the level of maternal education increases. For instance, while 21.5 percentage of children with reported cases of diarrhoea are born to mothers with no formal education, 11.9% are born to women who completed primary education while just 7.4% are born by women who attained higher education. Vaccination coverage also follow similar trend,

about 93% of children whose mothers have more than secondary education were fully vaccinated,  compared  with  23.9%  of  children  whose  mothers  had  no  education.  (MICS,

2016/17).

Also, inequality in child health outcomes exists across the six geopolitical zones in Nigeria with more of the disadvantaged children coming mostly from Northern Nigeria (Anyamele et al, 2017). In this part of the country, the level of women educational attainment is low when compared with their counterparts from the Southern part (Multiple Indicator Clustery Survey-

3, 2017). Furthermore, data from the Multiple Indicators Clusters Survey, 2016/17 shows that

North West which recorded the highest level of child mortality and Under – 5 mortality rate of

83 and 162 per 1,000 live births respectively, also had the least percentage of literate women of

38% while the South-West with a very high proportion of literate women (94.8%), had the least child mortality rate of 16 deaths per 1,000 of the population.

According to Cleland  et al (1991), educational  attainments  cum socio-economic status of women impacts children‟s health status because they exert influence on the individual mothers‟ knowledge,  personality  codes,  attitudes  and  behaviour,  which  in  turn  affect  the  health outcomes of their offspring. Nevertheless, such questions as the type and nature of education needs that would be critical for improved health outcomes in children, the degree of variability in  the  impact  of  education  on  health  as  well  as  the  channels  through  which  education influences morbidity and mortality for the various regional divides in Nigeria calls for research attention. From the foregoing, maternal education is a crucial policy variable through which the existing inequality in child health outcome in Nigeria could be mitigated. It is against this backdrop that the present work seeks to investigate empirically the trajectories through which maternal education influences under-five morbidity and mortality as well as the variability in the nature of impact for the different geopolitical divides in Nigeria.

1.2.   Statement of the Problem

According to the UN Inter-agency Group for Child Mortality Estimation (UN IGME) Report,

2017; Nigeria was the second largest contributor to global under – 5 mortality rates in 2016 with a very low annual rate of reduction in Under – 5 mortality rates of (2.7%). The country is one of the six countries that account for half of the total global under-five deaths, including, India, Nigeria, Pakistan, the Democratic Republic of the Congo, Ethiopia and China. The Table below shows the six countries with highest number of deaths among children from 0 – 59 months with their respective annual rate of reduction (ARR). The low annual rate of reduction

in  under-five  mortality  in  Nigeria  could  be  further  linked  to  low  national  immunization coverage rates, which is traceable factors such as women education, attitude and belief system. Evidently, if nothing is done to reverse the current trends, Nigeria will be one of the countries that will miss the SDGs target for neonatal and under-five mortality by 2030.

Incidentally, the Federal government of Nigeria with support from various development partners, including the World Health Organization (WHO), UNICEF, the UK Department for International Development (DFID), the United States Agency for International Development (USAID), implemented various policies and programmes to curb the menace of childhood morbidity and mortality in various parts of the country. Some of which include the Integrated Maternal, Newborn and Child Health (IMNCH) strategy launched in 2007 to accelerate the achievement of the MDGs; the Roll Back Malaria programme (RBM) 2009 and the Nigerian National Routine Immunization Strategic Plan (2013-2015) implemented with assistance from to the United Nations International Children Emergency Fund (UNICEF), the United Nations Development   Programme   (UNDP),   the   United   Kingdom   Agency   for   International Development (UKaid) to mention but a few. Nevertheless, despite the concerted international and national efforts towards combating the undesirable levels of infant and child mortality, this threat remains a daunting challenge in Nigeria. Nigeria was unable to meet the Millennium Development Goal (MDG 4) and no research has been able to point directly to the key policy hitches that made the realization of these targets impossible.

According  to  the  Nigeria  National  Demographic  and  Health  Survey  (NDHS,  2013);  15

Nigerian children die before reaching age 1, while one in every eight do not survive beyond their fifth birthday; resulting from vaccine Preventable diseases (VPD), acute respiratory infections (ARIs), diarrhoea, malaria and chronic malnutrition, which is not unconnected with the low levels of education amongst women of childbearing age. (NDHS, 2013).  Though the NDHS Report suggested that Nigeria has over the years, recorded little progress in the performance of core indicators of child health outcomes but the rate of reduction is slow for the country to achieve UN Sustainable Development Goals (SDGs) by 2030 (Morakinyo & Fagbamigbe, 2017). Available statistics from various NDHS Reports (2008 and 2013) shows that  the prevalence or case fatality rate of diseases  such as  diarrhoea,  malaria and  acute respiratory tract infections (ARI) has shown some level of decline from 1999 to 2013 while vaccine coverage has recorded little increase and with less percentage of children without vaccination at the end of the first 12 months of life, with under 5 mortality rates marginally declining especially from 2003 to 2013.

Interventions such as immunisation and early treatment of common childhood illnesses which have been seen to be the most cost-effective ways of preventing many under-five deaths and reducing the duration and severity of childhood illnesses are not adopted by most mothers in Nigeria. Nigeria has recorded progress in some of its health indicators, such as in infant and under-five mortality rates, while other areas showed slow progress or have worsened over the years. (UNICEF – SOWC, 2016).

Data from both the NDHS, 2013 and MICS 2016/17 reveal that, Nigerian children born to mothers with no formal education are about 3 times as likely to die before age 5 as children whose mothers have higher than a secondary education. Observably, the pattern of inequality in child health outcomes in Nigeria, place at a disadvantaged position the Northern population where the level of maternal education is relatively low, resulting to poor socio-economic status which worsen the ability to prevent or treat cases of childhood morbidity. Evidence from national survey Reports (NDHS, 2013 and MICS, 2016/17) indicates that there persists a high- level inequality in the level of women education in Nigeria with the disadvantaged regions, mostly the Northern part of the country, also recording low levels of vaccine coverage, high prevalence rate of childhood diseases as well as very low probability of child survival. For instance, data from the NDHS, 2013 shows that inequality in maternal education translates disparity in vaccination coverage which favour the residents in the urban areas where vaccination coverage is 43% as against the 16% in rural areas. Full vaccination coverage varies by zone with the regions where women education is low being the most vulnerable, ranging from 10% of children in North West Zone to 52% in South East and South-South Zones.

The Multiple Indicators Clusters Survey, MICS 2016/17; highlighted that 164-under-five mortality rate are associated with children born to women without any formal education while mothers whose level of education is more than secondary school record 55 under-five mortality rate. According to the Report, despite the fact that vaccine Preventable diseases account for 40 percent of all childhood deaths in Nigeria, over 75 percent of Nigeria‟s children age 0 to 59 months  were not  fully  immunized  with  the  North  West  and  North  East  having the least percentage of literate women in 2016 which is about 38% and 41.9% respectively, also recording the highest level of under – 5 mortality rate of 162 and 115 per 1,000 live births. As shown in the Table above, child health outcome across the six geopolitical zone varies with the number of years spent in formal education by women of childbearing age (15-49 years). In many instances, full vaccination is high for any region that has high percentage of educated women and vice versa.

Nigeria has signed unto the current UN Sustainable Development Goal (SDGs) with renewed commitment  to  end  Preventable  deaths  of  new-borns  and  under  five  children;  reducing neonatal mortality to at least as low as 12 per 1,000 live births and under-five mortality to at least as low as 25 per 1,000 live births or fewer in every country by 2030. However, a serious source of policy concern is that at the current rate of under – 5 mortality and the annual rate of reduction, the fears are that Nigeria might not be able to realize target of the UN Sustainable Development Goal (SDGs). Achieving this renewed commitment is dependent on monitoring the sources of Preventable deaths among children and tracking the channels through which they occur in order to evolve robust intervention strategies that would help close the existing gaps.

The existing high level of vulnerability among women in various parts of the country which could be due to poor levels of education, exposes their children to greater chances of morbidity and  mortality.  Interestingly,  various  research  linking  women  education  and  child  health outcome have been undertaken in Nigeria, but the prevalence rate of Preventable deaths is still very high. This has been attributed to the policy gap existing in the maternal and child health system in Nigeria which does not consider the pathway of influence through which maternal education could influence child health effectively.

Worthy of note is the fact that several research efforts have been directed towards identifying the proximate determinants of child mortality in Nigeria (Antai and Moradi, 2010; Adeboye et al, 2010, Adjuik et al, 2010; Becher, 2010; Okoro et al, 2009; Ekenze, 2009; Grais et al 2007; Oniyangi et al 2006).   Though most of these studies analysed the relationship between the socio-economic status of women and child health, the present study takes a unique examination of the importance of maternal education in driving other socio-economic variable towards influencing child health and mortality. Also, no Nigeria specific studies known to us, have been able to examine the linkage between maternal education and child morbidity which could lead to child mortality.

Despite the general knowledge that maternal education is linked with better health outcomes in children,  the  potential  pathways  linking  these  two  variables  in  Nigeria  have  not  been sufficiently explored. Consequently, more research effort is therefore needed to trace these relationships to be able to come up with appropriate intervention policies and programmes to address the daunting challenge of child health logically. In view of this, this study aims to advance the existing knowledge by examining the critical role women education could play in

influencing the incidences and avoidance of diseases capable of causing death among children in Nigeria.

1.3.   Research Questions

i.      Is there a relationship between maternal education and under-five mortality in

Nigeria?

ii.      How does mothers‟ level of education affect childhood morbidity in Nigeria?

iii.       Does  zonal  disparity  in  maternal  education  explains  variations  in  under-five mortality across Nigeria‟s six geopolitical zones?

1.4.   Objectives of the Study

The broad objective of this study is to investigate the effect of maternal education on child health and survival in Nigeria.  The specific objectives of the study are;

i.      To estimate the effect of maternal education on under-five mortality in Nigeria. ii.       To ascertain the effect of maternal education on childhood morbidity in Nigeria.

iii.       To  verify  whether  zonal  disparity  in  maternal  education  explains  variations  in under-five mortality rates across Nigeria‟s six geopolitical zones.

1.5.   Research Hypotheses

The study hypotheses are:

Ho 1: Maternal education has no effect on under-five mortality in Nigeria.

Ho 2: Maternal education does not have any influence on childhood morbidity in Nigeria.

Ho 3: Zonal disparity in maternal education has no influence on the variations in under-five

mortality rates in Nigeria‟s six geopolitical zones.

1.6.   Significance of the Study

Considering the position of child health status as a measure of development, it is important to focus research efforts on childhood morbidity as a trail to under 5 mortalities in Nigeria in order to generate new scientific evidence on how best to use educational policies and women empowerment as a tool for tackling this problem. This work shall be useful to key players and policy  makers  in  Nigeria‟s health  sector  to  understand  the  importance  of  mainstreaming maternal education in the implementation of strategy of the National Child Health Policy of

2016 and help in shaping other policies and programmes designed to ensure that Nigeria attains

the „Sustainable Development Goals‟ SDGs targets by 2030. The study will also help in reducing the level of Preventable deaths among under–5 children through increasing the upscaling routine immunization coverage using maternal education programmes as a catalyst to reduce detrimental beliefs and practices capable of undermining child health and survival in Nigeria.

Clearly, Nigerian studies on infant and child mortality have examined the influence of key determinants of infant and child mortality at various levels (individual, household, and community-levels) but the present study differ in its approach by considering mother‟s level of education as the trajectory through which most of the determinants of childhood mortality operates while isolating childhood morbidity as critical pathway worthy of examination. Intuitively, except for death caused by accidents or disasters, before mortality, there is usually a disease condition that could culminate into death if not managed effectively. The present study differs from others by its examination of morbidity as a pathway to mortality in under- five children. Consequently, the examination of the differential effect of maternal education on morbidity and mortality, would be valuable in vulnerability mapping and intervention planning especially as  it  concerns  the upscale of  girl  child  education  equitably within  the various geopolitical divides in Nigeria. In view of this, this study aims to uniquely extend the frontier of knowledge by examining the critical role of maternal education in influencing the health and survival of under-five children in Nigeria.

1.7.   Structure of the Study

This research work consists of five chapters.  Chapter one gives a general background of the study and the motivation behind the work.    It includes a general introduction and trends of under-five mortality in Nigeria, statement of the problem under study, objectives of the study, justification and limitations of the study. In chapter two, selected research works that are related to under-five mortality, the logistic regression and the alternating logistic regression are reviewed.  Chapter three discusses the data and an in-depth explanation of the methods used. In chapter four the data is explored, analyzed and discussed  using the STATA statistical software to get results.  The last chapter presents the conclusions and policy recommendations of the study.

1.8.   Scope of the Study

This study is a country specific study and for convenience, representativeness and instrument reliability, employed secondary cross-sectional data from the Nigeria Demographic and Health Survey (NDHS, 2013). The 2013 NDHS sample was selected using a stratified three-stage cluster design consisting of 904 clusters, 372 in urban areas and 532 in rural areas. A representative sample of 40,680 households was selected for the survey. All women age 15-49 who were either permanent residents of the households in the 2013 NDHS sample or visitors present in the households on the night before the survey were eligible to be interviewed. The study design enabled the researcher to draw evidence-based inference into the level and nature of association existing between maternal education and childhood morbidity and mortality across the six geopolitical zones in Nigeria using a national representative statistic obtained from  the  2013  NDHS  dataset  (Child  Recode  file)  and  (Women  Individual  Recode  file) including both the rural and urban areas in Nigeria.

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