Impact of Maternal Education and Health Related Behaviors on Infant and Child Survival in Pakistan G. Mustafa Zahid University of Western Ontario London, Ontario

Research Question  What is the nature of the association between mother’s schooling and child mortality on the one hand, and between the health seeking behavior of the mother and child mortality on the other hand?

Introduction  The level of infant and child mortality is widely used not only as a demographic measure, but also as an important indicator of the level of the health in a society and of its living standard.  Women are known and considered all over the world as the first providers of health care in the home. Mother’s behavior has a great impact on health and survival of children through curative means when the child is sick, whether the mother uses modern medicine or traditional practices.

Introduction (contd. i)  Prenatal visits enable mothers to obtain health information on prevention as well as specific medical attention which results in low morbidity and mortality in developing countries. Therefore, the mother’s behavior in seeking health either as a preventive or curative treatment is an important factor in determining child survivorship through the child’s health and nutritional status, as well as through her own health.

Introduction (contd. ii)  Women are expected by policy makers and society in general to implement the child survival revolution by: 1. Bringing children to be immunized four times during the first year of life; 2. Procuring or producing oral re-hydration solutions and administering them to a sick child many times over the course of each day of every bout of diarrhea; 3. Breastfeeding their babies on demand until the child is six months to two years old and processing and feeding proper weaning foods in frequent meals to small children at the appropriate ages; 4. Bringing children under age five to a weight surveillance program monthly.

What is Health Seeking behavior  Health seeking behavior includes consulting a physician during the prenatal (for mother’s immunization against tetanus), ante-natal (place of delivery and help at delivery) and postnatal (immunization of the child) period, especially when disease symptoms are aparent.

Previous Studies  Bicego and Boerma, 1993; Rajna et al., 1998; Caldwell, 1979,1987, 1990, 1994; Desai and Alva, 1998; Hobcraft et al., 1984; Martin et al., 1983; Sathar, 1985; D’Souza and Bhuiya, 1982; Streatfield, 1992.

Theoretical Framework Socio-economic determinants Maternal factors Environmental Contamination Nutrient deficiency Injury HealthySick Growth Faltering Mortality Personal Illness Control Treatment Prevention Source: Mosley and Chen 1984, PDR Supplement 10: 25-45

Objectives  To examine the pattern of health seeking behavior of mothers and its effects on childhood mortality.  To examine and compare the effects of socio-economic factors through demographic and health seeking behavior especially education of mother on childhood mortality.

Source of Data and Method of Analysis  Data derive all its variables under study from the Pakistan Demographic and Health Survey (PDHS) of , a nationally representative survey covering all four provinces of the country, the first and up till now the latest survey undertaken by Macro International in conjunction with the National Institute of Population Studies (NIPS).

Continued (methods)  The dependent variable is the survival times of the children during neonatal, infant and childhood ages. Since many children have not completed the event at the date of survey these observations were considered as censored. Cox’s proportional hazard model is appropriate for the analysis of data that includes censored observations. Unlike parametric models, the proportional hazard model does not make any assumption on the distribution of the timing function and thus appropriate for events whose empirical distribution of the timing function is unknown.

1) Summary Results: Neonatal CovariatesRegression CoefficientsExp (β) Age of mother at Birth ** **0.912 Birth Order *** **1.464 Immunization No Incomplete-1.863**0.155 Complete-3.906***0.020 Ever-breastfed Yes No2.302*** Antenatal Care Doctor/ LHV / Nurse Traditional0.351***1.421

Continued: Neonatal CovariatesRegression CoefficientsExp (β) Education of mother No Education Primary/ Middle-0.161**0.851 Secondary/ Higher-0.152**0.859 Sex of Child Male Female Type of Toilet Facility Flush Others Place of Residence Urban Rural0.152**1.164 Tetanus Injection in Pregnancy Yes No0.508***1.662 * Significant at level <0.10, ** < 0.05, and *** <0.001

2: Summary Results: Infants CovariatesRegression CoefficientsExp (β) Age of mother at Birth ** **0.485 Birth Order *** **1.349 Immunization No Incomplete-1.547**0.213 Complete-1.208***0.299 Ever-breastfed Yes No1.519***4.566 Antenatal Care Doctor/ LHV / Nurse Traditional1.076***2.932

Continued: Infants CovariatesRegression CoefficientsExp (β) Education of mother No Education Primary/ Middle-0.457*0.633 Secondary/ Higher-0.398***0.672 Sex of Child Male Female Type of Toilet Facility Flush Others0.113**1.120 Place of Residence Urban Rural0.147**1.158 Tetanus Injection in Pregnancy Yes No0.498***1.645

3: Summary Results: Children CovariatesRegression CoefficientsExp (β) Age of mother at Birth *** *0.526 Birth Order ** *3.059 Immunization No Incomplete-0.659*0.517 Complete-0.755***0.470 Ever-breastfed Yes No1.015**2.760 Antenatal Care Doctor/ LHV / Nurse Traditional1.042**2.835

Continued: Children CovariatesRegression CoefficientsExp (β) Education of mother No Education Primary/ Middle-0.102***0.903 Secondary/ Higher-0.491***0.612 Sex of Child Male Female0.072***1.075 Type of Toilet Facility Flush Others0.687**1.988 Place of Residence Urban Rural0.127**1.136 Tetanus Injection in Pregnancy Yes No

Conclusion  The highest mortality occurred among children born to mothers aged less than 20 years.  Neonatal and infant mortality is higher for males than for females; this relationship is then reversed for child mortality. This shows that there are some gender related differences in child rearing practices that favor boys over girls.  The high mortality of first and high order births may be related to the age of the mother at the child’s birth which is termed as high risk births for very young and older mothers.

Conclusion (continued)  The analysis identifies that the mothers who have a better perception of disease processes and an excellent aptitude to utilize modern health services are qualitatively distinct from those who do not.

Conclusion (continued)  Differences in infant and child mortality have also been observed according to the place of residence at the time of the survey. Mortality is higher in rural areas than in urban areas as expected. This finding might be due to factors including sanitation, water supply, and unequal distribution of health facilities between rural and urban areas of the country.

Conclusion (continued)  The important conclusion from this analysis of differentials in infant and child mortality is that mother’s education and age at birth are strongly correlated with lower neonatal and infant mortality.