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Research
Girls’ hidden penalty: analysis of gender inequality in child mortality with data from 195 countries
  1. Neelam Iqbal1,
  2. Anna Gkiouleka2,
  3. Adrienne Milner3,
  4. Doreen Montag3,
  5. Valentina Gallo3,4,5
  1. 1 BSc in Global Health, Centre for Primary Care and Public Health, Queen Mary, University of London, London, UK
  2. 2 Department of Sociology, University of York, York, UK
  3. 3 Centre for Primary Care and Public Health, Queen Mary, University of London, London, UK
  4. 4 Epidemiology and Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
  5. 5 School of Public Health, Imperial College London, London, UK
  1. Correspondence to Valentina Gallo; v.gallo{at}qmul.ac.uk

Abstract

Introduction Gender inequality has been associated with child mortality; however, sex-specific mortalities have yet to be explored. The aim of this study is to assess the associations between gender inequality and the child mortality sex ratio at country level, worldwide and to infer on possible mechanisms.

Methods Data on sex-specific under-five mortality rates (U5MR) and the corresponding sex ratio (U5MSR) for the year 2015, by country, were retrieved from the Unicef database. Excess under-five female mortality was derived from previous published work. Gender inequality was measured using the Gender Inequality Index (GII). Additional biological and social variables have been included to explore potential mechanistic pathways.

Results A total of 195 countries were included in the analysis. In adjusted models, GII was significantly negatively associated with the U5MSR (β=−0.29 (95% CI −0.42 to –0.16), p<0.001) and borderline significantly positively associated with excess under-five female mortality (β = 3.25 (95% CI −0.28 to 6.67, p=0.071). The association between GII and U5MSR was strong and statistically significant only in low-income and middle-income countries and in the Western Pacific area.

Conclusion The more gender unequal a society is, the more girls are penalised in terms of their survival chances, in particular in low-income and middle-income countries. In order to decrease child mortality and excess girl mortality, global policy should focus on reducing gender inequality surrounding measures of reproductive health, women’s political empowerment, educational attainment and participation in the workforce.

  • gender inequality
  • gender inequality index (GII)
  • child mortality
  • child mortality sex ratio
  • ecological analysis

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: http://creativecommons.org/licenses/by/4.0

https://doi.org/10.1136/bmjgh-2018-001028

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    Footnotes

    • NI and AG contributed equally.

    • Handling editor Seye Abimbola

    • Contributors VG has full access to all data in the study, has conducted the statistical analysis, and takes responsibility for their integrity and the accuracy of the data analysis. She declares that this manuscript is honest, accurate and transparent account of the study being reported and that no important aspects of the study have been omitted. All co-authors had full access to the data (including statistical reports and tables) and can take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: VG. Analysis and interpretation of data: NI, VG, AG, AM. Drafting of the manuscript: VG, NI. Data collection: VG, NI. Critical revision of the manuscript for important intellectual content: AG, AM, DM.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Patient consent Not required.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement All the data used for this article are already publicly available.