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Nigeria is a country with one of the world’s highest rate of under-five mortality. Any innovative research aimed at bringing solutions to this problem should be considered worthwhile. This study examined how socio-economic, demographic and cultural factors (called underlying factors), influence under-five mortality in Nigeria by identifying some other direct factors (called proximate determinants) through which the underlying factors influence under-five mortality. It used data from the Nigeria Demographic and Health Survey (NDHS) of 2013. Mothers of 31,482 children born during the previous five years of the survey were interviewed on survival status of their children and also on their own characteristics and child healthcare practices. The Mosley and Chen framework for child survival was adopted to explore the pathways of influence of the underlying factors on under-five mortality. The underlying factors considered are mother’s age, marital status, education, occupation, geographical region of residence, urban/rural residence, wealth status and religious affiliation. The proximate determinants examined are, child’s birth order, number of births mother had within the previous five years of the survey, whether or not the child was ever breastfed, the household source of drinking water, type of toilet facility, type of cooking fuel and the place where the child was delivered. Statistical analyses used were the univariate, bivariate and the multivariate analyses. Due to the binary nature of the dependent variable (Dead or Alive), the multivariate analysis technique adopted was the “binary logistic regression”. The level of significance was set at 5 percent. Findings showed that all the nine underlying factors had a significant indirect bivariate relationship with under-five mortality. At the multivariate analysis level, all the underlying factors except religion and occupation maintained their significant indirect effects on under-five mortality. Further, the children who were never breastfed were twenty times more likely to die before five years of age than children who were ever breastfed (P < 0.001). The Log Likelihood Ratio (LR) test used to examine the overall level of importance of the proximate determinants as pathways of influence of the underlying factors on under-five mortality found them to be highly significant (Chi-square = 3222.423 on 12 degrees of freedom, P < 0.001). However, several of the underlying factors still maintained their significant relationships with under-five mortality after adjustments for the seven proximate variables. The result implies that, in addition to the seven proximate determinants used, there must be other proximate variables not included in the study through which the underlying factors are also influencing under-five mortality. Given that proximate determinants (e.g., child spacing), have direct effects on mortality, policies and programmes targeted to influence them will be more effective and in reducing under-five mortality than those targeted to influence underlying factors (e.g., providing higher education for women). The study conclude by recommending programmes such as those that create awareness of mothers about practices that prevent childhood mortality including extensive and prolonged
breastfeeding and use of contraceptives which help to prevent frequent or multiple births within short intervals, thereby reducing the high under-five mortality in Nigeria. Keywords: Under-five mortality, Underlying factors, Proximate determinants and Pathways of Influence
List of Abbreviations
Federal Ministry of Health, Nigeria
Millennium Development Goals
Nigeria Demographic and Health Survey
National Population Commission
Sustainable Development Goals
United Nations Development Programme
United Nations Children’s Fund
United State Agency for International Development
1.1 Background to the Study
Under-five mortality refers to the death of children below the age of five years (National Population Commission (NPC) [Nigeria] and ICF International, 2014). Though most of the deaths that occur at the early stage of life are preventable, under-five mortality continues to be a topical issue in the field of public health (Oyefara, 2013; United Nations Children’s Fund -UNICEF, 2014; UNICEF, 2015). Goal number 4 of the recently concluded Millennium Development Goals (MDGs), focused mainly on reducing under-five mortality worldwide by 66 percent between 1990 and 2015 (Federal Ministry of Health, Nigeria- FMOH, 2010; Sawyer, 2012; UNICEF, 2013). Although a global decline from 91 deaths per 1,000 live births in 1990 to 43 deaths per 1,000 live births in 2015 was recorded (i.e., a decline of 53 percent), child survival in developing countries had not improved appreciably, especially in South Asia and sub-Saharan African countries (United State Agency for International Development- USAID, 2014; UNICEF, 2015).
The MDG progress report of 2013 showed that at the country level, only one-fifth of the countries with the high mortality rate of 40 deaths per 1000 and above had the chance of achieving MDG Goal 4. Hence, the world would still not have met the target until 2026 (11 years behind the MDGs schedule) if the trends in 2013 had continued in all countries (UNICEF, 2015). It was because of this lack of sufficient progress to reduce under-five mortality by many of the developing countries at the target year, that the issue remains one of the focus of the newly adopted Sustainable Development Goals (SDGs), which aim at reducing under-five mortality to 25 per 1,000 or fewer by 2030 (United Nations, 2015).
Among the countries in sub-Saharan Africa with high under-five mortality is Nigeria (NPC and ICF, 2014; UNICEF, 2014). The under-five mortality rate in 1990 was 201 deaths per 1000, which later declined to 128 deaths per 1000 in 2013 (NPC and ICF, 1999). That is 36 percent decline within the 23 years period. Nigeria, therefore, was far short of achieving the MDG 4 (NPC [Nigeria] and ICF, 2014). However, the progress being made in reducing under-five mortality in Nigeria will continue to be intensified and
monitored in the post-2015 Millennium Development Goals (MDGs) global agenda (National Bureau of Statistics, Nigeria, 2014).
Socio-economic, environmental, cultural and behavioural factors are known to influence under-five mortality. For Nigeria to achieve the SDG 3, it is important to have a good understanding of the way and manner these factors operate to influence under-five mortality in Nigeria so that effective policies and programmes can be put in place to accelerate the reduction of under-five mortality. Although some studies had attempted to examine the factors of childhood mortality in Nigeria, only a few had tried to explain or disentangle the process by which these factors operate to exert their effects on under-five mortality. For example, Fayehun and Omololu (2009), examined the effects of the ethnicity of the mother on childhood mortality in Nigeria, but their study failed to show how ethnicity could be interacting with other factors to produce the observed effects on under-five mortality.
Other studies that have identified the determinants of under-five mortality in Nigeria are Antai (2010) and Adedini (2013). Using Nigeria Demographic and Health Survey (NDHS) data of 2003, Antai examined the effects of social context and position of the mother on under-five mortality, but he also failed to clearly disentangle how those factors operate to influence under-five mortality. Adedini focused on the contextual determinants of under-five mortality using the NDHS data of 2008. His study examined the independent effects of characteristics related to the child, mother, household and the municipal factors where the child resides on under-five mortality. Even though he used some maternal and biological factors as intervening variables, he did not clearly show their pathways of influence on under-five mortality.
1.2 Statement of the Research Problem
The loss of a child can constitute a deeply distressing or disturbing experience for a parent or family. For a population or community where the frequency of child death is high (i.e., high childhood mortality rate) the potential economic loss can be very huge,
not talk of the social and psychological implications or consequences of such losses. In such a population, any efforts or investments to reduce childhood (under-five) mortality will be considered to be worthwhile. The welfare or health status of a population may be judged by the level of its childhood mortality. As it was stated earlier, Nigeria is one of the countries of the world with the highest under-five mortality rate. She, therefore, has a high urgency to reduce her level of under-five mortality. This study provides a means of doing that.
Studies have shown that under-five mortality is influenced or determined by various social, economic, demographic, environmental, cultural or behavioural factors. Some of these factors influence under-five mortality directly and others affect it indirectly (Antai, 2010; Buwembo, 2010; Kuate-Defo, 1993; Mosley and Chen, 1984). Those factors that have indirect effects on under-five mortality are referred to as the underlying (or background) factors (Mosley and Chen, 1984; Mosley, 2006). Examples include; mother’s education, wealth status, place of residence, religion, etc. While, those factors that have direct effects on under-five mortality are called the proximate determinants (Mosley and Chen, 1984; Mosley, 2006). Examples of such variables include; birth order, type of birth - i.e., single or multiple, breastfeeding, immunization, the source of drinking water, etc.
According to the analytical framework designed by Mosley and Chen (1984), the underlying factors necessarily operate through the proximate determinants to influence under-five mortality. However, not many studies have considered the link between the underlying and proximate factors when examining under-five mortality in developing countries with varying nuances. While some had taken underlying factors as if they had direct relationship with under-five mortality (Ogunjuyigbe, 2004; Uddin, Hossain and Ullah, 2009; Mondal, Hossain, and Ali, 2009; Tette and Owusu, 2014), others had only tried to explain the direct effect of the proximate determinants on under-five mortality without any consideration for the underlying factors (Buwembo, 2010; Bello and Joseph, 2014; Rutstein, 2005). These are major gaps in the understanding cause-effect relationship in under-five mortality studies.
The study by Ogunjuyigbe (2004), examined the traditional beliefs of the mother on under-five mortality. He treated the socio-economic variables (underlying factors) as if they have direct effects on under-five mortality. Further, Kayode, Adekanmbi and Uthman (2012) in their own study examined maternal and biological factors that constitute a risk or are predictors of under-five mortality. They presented in their multivariate analysis using the cox hazard proportional regression the direct effects of those medical factors on the outcome variable without considering the link they might have with the background or underlying factors before they can influence under-five mortality.
Some studies even end up surmising the underlying and proximate factors, with the assumption that they both influence under-five mortality in similar ways (Fayehun and Omololu, 2009; Antai, 2010; 2011). There is, therefore, scarcity of studies that have used the approach of underlying and proximate factors linkage in examining under-five mortality in Nigeria. Researches that have been able to bring to use the proximate determinants approach in studying under-five mortality in Nigeria had in most cases used only descriptive or bivariate analyses to explain the variables. Caldwell (1979), examined the effects of mothers’ education on under-five mortality in Nigeria and he was able to adequately use the proximate determinant approach in his study. His findings showed that an educated mother is more likely to utilize health care services compared to an illiterate mother who may not be able to communicate the health conditions of her child to the health personnel. But the study was limited in that, he only used bivariate analysis to explain the relationship that existed between the background factors (underlying factors) and the proximate determinants before they can influence under-five mortality. That is, he failed to look at other background factors that may be confounding or interfering with the influence of maternal education on under-five mortality.
Also, Olisaekee (2014) investigated the effects of energy poverty (i.e., types of cooking fuel used in the households) on under-five mortality using the proximate determinants approach. Her work was mainly a review of previous studies on under-five mortality in Nigeria. Hence, she was unable to statistically or independently establish her main
objective/hypothesis that, energy poverty influence under-five mortality through proximate determinants such as exposure to smoke (i.e. environmental factors) by using the appropriate multivariate statisti
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