Maternal education and child nutritional status in Bolivia: finding the links
Introduction
Child health and survival in Bolivia continue to be issues of national and international concern. Bolivia has some of the highest rates of infant and child mortality, morbidity, and malnourishment in the region (Boerma, Sommerfelt & Rutstein, 1991; Pimental & Garcı́a, 1995; Sommerfelt & Stewart, 1994; Sullivan, Rutstein, & Bicego, 1994). For example, the 2003 Bolivian infant mortality rate of 61 per 1000 live births contrasts sharply with Bolivia's geographical neighbors, ranging from 10 deaths per 1000 live births in Chile to 33 deaths per 1000 births in Peru (Population Reference Bureau, 2003). In 1998, approximately 29 percent of Bolivian children younger than 5 years of age were malnourished; this is a larger proportion than any other country in South America (Demographic and Health Surveys, 2002). These rates escalate among high-risk Bolivian populations, such as indigenous populations in the Altiplano region (República de Bolivia, 1994; Pimental et al., 1995).
Beginning with the work of Caldwell (1979), a considerable body of research suggests that maternal education is the single most important factor in explaining differentials in child health outcomes, more important than paternal education, health service availability, and socioeconomic status (Martin, Trussell, Salvail, & Shah, 1983; Young, Edmonston, & Andes, 1983). Comparative studies in all major regions of the developing world have shown a linear relationship between education and childhood mortality (Bicego & Ahmad, 1996; Cleland & Van Ginneken, 1988; Ware, 1984; Cochrane, 1980; United Nations, 1985).
However, more recent research calls into question the causal association between maternal education and child health outcomes (Desai & Alva, 1998; Basu, 1994; Hobcraft, 1993). In particular, Desai and Alva (1998) concluded that maternal education is mostly a proxy for socioeconomic status and geographic area of residence: thus, the effect of maternal education disappeared or was greatly reduced once controlling for these factors. Thus, there is continued debate regarding the influence of maternal education on child health outcomes; additional research is needed to further understanding of how maternal education impacts child health (Barrett & Brown, 1996; Bicego & Boerma, 1993; Desai & Alva, 1998). It is this gap in the literature that we attempt to address.
Specifically, we use data from the 1998 Bolivia Demographic and Health Survey in this study to explore several specific pathways through which maternal education likely influences child nutritional status, and we analyze the relative contribution of each pathway. These pathways include socioeconomic status, knowledge, modern attitudes about health care, autonomy, and reproductive behavior. Bolivia is one of the poorest nations in Latin America, with a gross national income of $2240 in 2001 US dollars (Population Reference Bureau, 2003), and it provides a useful context for studying the linkages between education and child nutritional status in a disadvantaged setting. In order for policy makers to better promote change and improve child well-being in impoverished regions, it is necessary to more completely identify the mechanisms through which maternal education is associated with child health outcomes.
Section snippets
Conceptual model
Various studies have attempted to model the effects of female education on child survival and health outcomes. Mason (1984) hypothesized various pathways linking female education and infant and child mortality. Her model included contraceptive use, female autonomy, and family socioeconomic status as potential pathways. LeVine, Le Vine, Richman, Tapia Uribe and Sunderland Correa (1994) linked female schooling to fertility and child survival through intervening mechanisms including the
Data
We model pathways of influence between maternal education and child nutritional status in Bolivia using the 1998 Demographic and Health Survey (DHS). The DHS interviewed 11,187 women between the ages of 15 and 49. A stratified cluster-sampling design was used to randomly select women aged 15–49 within each cluster. Sample cases are adjusted for over-sampling of particular areas and to compensate for differences in response rates. The survey was executed in four steps: (1) the sample was
Results
Descriptive statistics are presented first in Table 2. Approximately 30 percent of children aged 0–60 months are stunted in Bolivia, a relatively high proportion for Latin America. Overall, maternal education levels are low, with almost 60 percent of the children's mothers reporting 5 years of schooling or less, indicating that many women never progress past the basic education level.
Socioeconomic levels as measured by the wealth and environment indicators reflect high levels of poverty in
Discussion
In contrast to the findings of Caldwell (1979) and Martin et al. (1983), we find that part of the effect of maternal education on child health outcomes is explained by socioeconomic status. This finding is supported by Desai and Alva (1998). However, in contrast to their work, we find that only about half of the maternal education effect is explained by socioeconomic status and geographic residence. In addition, we account for about 65 percent of the maternal education effect on child
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