Introduction Child Mortality (CM) remains a problem in the - - PDF document

Introduction Child Mortality (CM) remains a problem in the developing countries. Despite high rate of under- five mortality in Nigeria, child health and living condition are often neglected as a result of lackadaisical stance of the government to the health of its citizens. Child survival in any nation can be affected by serious environmental problems that arise in the people‘s environment. Factors such as contaminated water, inadequate sanitation, smoky cooking fuels and infestation by insects can contribute to childhood mortality. Children, however, constitute one of the groups that are more vulnerable to health hazards that emanates from all these environmental factors. According to UNICEF (2010), approximately 8.1 million children under the age of five in the world died annually in 2009. Out of the reported child mortality in the world, not less than three million of them occur due to environmental related diseases (WHO, 2007). This has led both national governments and international organizations to commit efforts towards combating high child mortality in countries with high level of mortality. Child mortality has reduced worldwide for the past three decades due to various efforts put in

• place. However, despite these efforts toward improving child health, the decline in child

mortality in sub-Saharan Africa has been slower. According to United Nations (2002) and WHO (2005), out of the twenty countries with the highest child mortality in the world, nineteen of them are in sub-Saharan Africa, while Nigeria is identified as one of the high child mortality countries world-wide (UNICEF, 2011). In Nigeria, child mortality only declined from 199 per 1000 live births in 1990 to 128 per thousand live births in 2013 (NPC [Nigeria] and ICF Macro, 2014). Considering the regional distribution of child mortality in the country, the rate varies from 90per 1000 live- births in the South-West to 185 per 1000 live-births in the North-West (NPC [Nigeria] and ICF Macro, 2014). Compared with countries with high mortality, child mortality is higher in Nigeria. The two-third reduction in child mortality between 1990 and 2015 advocated by the Millennium Development Goals (MDGs) was unachievable. Therefore, in order to meet the Sustainable Development Goal

• f reducing child mortality, much is needed to be done, and this will include investigating the

various factors that are militating against child survival in the country.

This paper, therefore, aimed at determining how mortality of children under the age of five in Nigeria is related to the household environmental characteristics such as place of delivery, source

• f drinking water, sanitation facility, as well as access to good housing materials, as well as other

socio-demographic characteristics of the children so that drastic steps that will enhance child survival can be undertaken. According to available relevant literatures, several factors have been identified with high child mortality in Nigeria and other parts of the world (Mutunga, 2004). According to Mosley and Chen (1984), factors such as maternal, demographic, and socioeconomic factors were found to be important determinants of childhood mortality in developing countries. Several researchers have also linked childhood mortality with maternal health conditions of the parents, most especially of the mother (Caldwell, 1979; Balk, Pullum, Storeygard, Greenwell & Neuman, 2004). Household environmental factors such as the building construction materials, sources of water and types of toilet facilities, as well as cooking facilities have also been identified as risks factors

• f child mortality. A study in Southwestern part of Nigeria by Iyun (2000) identified maternal

factors and household environment conditions as some of the factors affecting childhood

• mortality. Another study by WHO (2002) identified unsafe water, sanitation and hygiene, indoor

smoke from solid fuels among the 10 leading causes of deaths in high-mortality developing

• countries. An estimate by World Bank also has it that environmental risk factors are responsible

for about one-fifth of the total burden of disease in low income countries (World Bank, 2001). In a similar study, WHO (2014) reported that about 60% of the infections killing children under the age of five are related to environmental conditions, most especially inadequate sanitation and contaminated water. Also, of relevance to health status of children is the Hygiene practices of their mothers. Although literatures have extensively linked social and economic conditions with children health status, poor data availability has limited investigation of the effects of environmental factors at the household level in most parts of the world (Buckley, 2003).

Potential environmental health risks have been categorized into two: the traditional hazard related to poverty and lack of development, such as waste disposal, vector borne diseases, inadequate sanitation, air pollution (indoor) and lack of safe water while the second emanated from the modern day hazards including rural air pollution and exposure to agro industrial chemical and wastes, caused by development that lacks environmental safeguards (Shyamsundar, 2002). We considered the first category in this study. To unravel the factors militating against the survival chances of under-five children in Nigeria, we explored effect of maternal environmental conditions on child mortality against the backdrop of limited research in this regard. Methods Study Area The study was conducted in Nigeria, the most populous country in Africa. Nigeria has a young population and the life expectancy is low and lower than the figure for sub-Saharan Africa (WHO, 2014.). Nigeria has a total population of 140,431,790, of which 17.1% of the total population constitutes children below the age of five during the last 2006 census with annual population growth rate of 3.2% (PRB, 2013). In Nigeria, the current total fertility rate is 5.5 (NPC [Nigeria] & ICF International, 2014), a reduction from the figure obtained in 1990. Under- five mortality in the country is put at 128 deaths per 1000 live birth. . Although one can say that Nigeria is still at the first stage of demographic transition, the country is predominantly rural and the literacy level is low. Sample and Sampling This study is an analytic and used quantitative secondary data from the Nigeria Demographic and Health Survey (NDHS) that was undertaken in 2013. The data was a nationally representative sample in 904 clusters (372 clusters in the urban and 532 clusters in the rural areas). The data set contains information on all women aged 15 to 49 years from 40,680 households. A total weighted sample of 31,828 births to women aged 15-49 years was selected for this study. The NDHS provides information on fertility, mortality, health issues, socio-economic and environmental conditions of the respondents. The 2013 NDHS particularly asked a number of questions about the household environmental conditions, including: the source of drinking water,

type of sanitation facility, type of flooring, walls, and roof, and number of rooms in the dwelling etc. The outcome variable was under-five mortality while the key explanatory variables were environmental factors. The outcome variable which is under-five mortality is dichotomous (1 if child is alive and 0 if child is dead)..The variables examined in this study, therefore, include children age, mothers‘ age at births of the children, education, religion, place of residence, working status, family type, region, wealth index, birth size, place of delivery, as well as environmental factors such as housing materials, hygiene practices, sources of drinking water etc. Compliance with ethical standards Ethical clearance for 2013 NDHS has already been received from National Health Research Ethics Committee. (Assigned Number: NHREC/01/01/2007). The researcher, therefore, sought the ethical permission from ICF Macro Inc. before using this set of data. Data analysis We carried out univariate, bivariate and multivariate data analysis. Frequency was used to describe the data and at bivariate level of analysis, Chi-square model was used to examine the association between childhood mortality experience for the index under five child and the independent variables. At the multivariate level, Cox regression model was performed to establish the influence of environmental factors on the risk of child mortality, amidst other variables like age, educational level, religion, place of residence etc. In the Cox regression, the number of months a child has lived was used as response to the time variable while the living status of the children was censored ―1‖ for alive and ―0‖ for dead. The data was weighted using appropriate weight - v005/1 000 to correct any imbalance that arose from either under-sampling

• r over-sampling. STATA statistical package, Version 20.0 was used for data analysis and

significance set at 5%.

Results Child Mortality by Children’ Backgrounds Characteristics The distribution of child mortality by background characteristics is shown in Table 1 below. The distribution of births in the study area revealed that, out of the 31,828 of the children born by the respondents in five years preceding the survey, 9.0 per cent (2,879) of the children died before attaining the age of five. Among the children that died, 40.8 percent died during infanthood, 33.8 percent between 28 days and one year, while 25.4 percent of them died between one year and before attaining five years of age. Male children (9.6%) were found to have excess mortality

• ver female children (8.4%). The distribution of child mortality among different age groups of

mothers further revealed that women of reproductive age in their middle age (15-24 years) reported lower child mortality of 8.4 percent, when compared with women in their early and later ages of their reproductive live which reported 9.6% and 9.8% respectively. Child mortality decreased from 10.9 per cent among women with no education to 4.9 per cent among women with higher education in the study area. According to the working status of the mothers, child mortality was a little bit higher among mothers that are not currently working (8.9%) when compared with mothers that are currently working (9.4%). Respondents‘ working status was found not to significantly affect child mortality in this study. The distribution of respondents according to their place of residence revealed that women living in urban areas have lower child mortality (6.5%) than women residing in rural areas (10.4%). The distribution of child mortality by family type revealed that women from monogamous family recorded the lowest childhood mortality when compared with their counterparts in single parent and polygamous families which reported childhood mortality of 10.1 percent and 10.6 percent respectively. Among different tribes in the country, women from Yoruba tribe have lowest child mortality (6.5%), while child mortality is higher among Hausa/Fulani women (10.9%). Those from Igbo/Ibibio reported 8.2 percent, while 7.8 per cent of women from other tribes reported child

• mortality. Among different religious groups in the country, those practicing Islam reported

highest mortality (10.0%), followed by the Traditionalists (9.4%),, while child mortality among Christians constitutes 7.5 per cent.

Child mortality among the respondents decreased as their wealth increases from 11.5 per cent among the poorest women to 5.0 per cent among the richest. Respondents‘ wealth index was found to significantly affect child mortality. In addition, the distribution of child mortality by number of births in the last five years revealed that child mortality increases along with the number of births; from 7.6 per cent among women with one or two births to 17.9 per cent among women with three or four births and to 33.8 per cent among women with five or more births. Similarly, child mortality also increases with the number of children ever born from 7.4 percent among women with one or two births to 10.9 percent among women with five or more births

Table 1: Child Mortality by Backgrounds Characteristics

Variables Categories Proportion dead (N=2,879) Total Women p-value Age of Mothers 15-24 25-34 35—49 755 (9.63) 1,331 (8.39) 793 (9.75) 7,834 15,866 8,128 0.0020 Mother’s Educational Level None Primary Secondary Higher 1,712 (10.93) 564 (9.20) 514 (6.26) 90 (4.88) 15,656 6,127 8,211 1,834 0.0000 Husband’s Educational Level None Primary Secondary Higher 1360 (11.03) 559 (9.50) 669 (7.40) 214 (5.68) 12,334 5,884 9,035 3,767 0.0000 Working Status Not Working Currently Working 924 (9.40) 1,947 (8.90) 9,823 21,864 0.2184 Family Type Single-Parent Monogamous Polygamous 135 (10.1) 1,680 (8.22) 1,044 (10.6) 1,337 20,426 9,851 0.0000 Place of Residence Rural Urban 723 (6.50) 2,156 (10.41) 0.00 Ethnicity Yoruba Hausa/Fulani Igbo/Ibibio Others 228 (6.47) 1,507 (10.9) 293 (8.17) 850 (7.81) 3,527 13,826 3,589 10,887 0.00 Religion Christians Islam Traditionalists 868 (7.45) 1964 (9.98) 28 (9.39) 11,650 19,679 300 0.00 Wealth Index Poorest Poorer Middle Richer Richest 859 (11.46) 872 (11.85) 468 (7.79) 413 (7.30) 267 (5.02) 7,496 7,355 6,001 5,656 5,320 0.00 Number of Births in the Last Five Years 1 or 2 Births 3 or 4 Births 5 births+ 2,070 (7.57) 792 (17.91) 16 (33.79) 4,423 49 0.0000 Children Ever Born 1 or 2 Births 3 or 4 Births 5 births+ 678 (7.4) 900 (8.16) 1,401 (10.89) 9,164 9,800 0.0000 Sex of Child Male Female 1,548 (9.64) 1331 (8.44) 0.0013 Age at Death 0 - 28 Days 29 days – Less than 1 Year 1 Year -Less than 5 Years 1,175 972 (33.8) 731 (25.4) 2,789 2,789 2,789

Source: 2013 NDHS data

Child Mortality by Health Related and Environmental Variables The distribution of childhood mortality by environmental factors is presented in Table 2. Distribution of child mortality by various sources of water indicated that those drinking water from rain (7.2%) and pipe/bore hole (8.3%) have lower mortality, while those drinking water from well (9.9%) and spring or river have higher mortality(9.94%). Women that used mosquito nets for their children had lower child mortality (8.4%) when compared with those that did not use it (9.4%). On the use of toilet facilities, those women that used flushed toilet have lower child mortality (5.6%) when compared with those that were using pit toilet (9.8%) and those using other sources (42.9%). In addition, those disposing their stool through toilet have higher child mortality than those disposing through other means. Also, respondents that shared toilet facilities with other people reported higher child mortality (9.8%) than those that do not share toilet facilities (7.0%). Further analysis revealed that toilet facilities and the way stool are disposed have significantly affected child mortality in the country. Housing materials are another factor that can affect human‘s survival. In this study those that use cement for roof and wall materials have lower child mortality (7.9% and 7.0% respectively) compared with those that used other materials. Both roof and wall materials were found to have significant effects on child mortality among women in the study area. On the size of child at birth, women that have children with very large size at birth reported lower child mortality of less 7.2 per cent when compared with their counterparts with child having very small size at births who reported 15.8 per cent. Another factor contributing to child survival is the child‘s place of birth. Women who delivered their children in hospital have lower child mortality of 6.8 percent when compared with those women who delivered their children at home and other places with reported child mortality of 9.8 percent and 8.6 percent respectively. Both antenatal and postnatal care can contribute immensely to both maternal and child health. The results of this study revealed that women with regular antenatal visits of more than four visits reported lower child mortality (5.0%), while those women with no antenatal visit recorded

higher child mortality of 7.1 percent. In a similar manner, women who made postnatal visits were found to have about half child mortality of those women who made no postnatal visit (3.4% vs 6.5%). Both antenatal and postnatal visits were however found to significantly affect child mortality in this study.

Table 2: Child Mortality by Health Related and Environmental Variables

Variable Proportion dead Total Women p-value Source of Water Pipe/Tap/Bore Well Spring/River Rain Others 1145 (8.29) 1,016 (9.88) 550 (9.94) 11 (7.17) 126 (7.07 13,812 10,283 5,534 152 1,775 0.0001 Mosquito Nets Used Net Didn‘t Use 916 (8.38) 1963 (9.40) 10,924 20,883 0.0088 Toilet Facilities Flushed Pit Bush/Composting/Bucket /Hanging Others 274 (5.57) 1,666 (9.78) 910 (9.44) 2 (42.88) 4,914 17034 9,634 4 0.0000 Toilet Facilities Shared Shared Not Shared 522 (7.02) 1,460 (9.76) 7,435 7,428 0.0000 Stool Disposal Toilet Garbage Buried Not Disposed 1,083 (6.25) 525 (6.02) 36 (6.06) 190 (7.22) 17,314 8,720 594 2,634 0.3011 Wall Materials No wall Cane/Palm/Trunks/ Dirt Bamboo/Stone with Mud Cement Others 71 (10.32) 1,450 (11.05) 207 (11.36) 1,079 (6.98) 58 (9.27) 688 13,121 1,825 15,456 631 0.00 Roofs No Roof Thatch/Leaf Rustic Mat/Palm/Bamboo Metal Cement/Tiles Others 43 (10.25) 590 (10.02) 318 (13.94) 1824 (8.28) 74 (7.93) 2 (11.17) 416 5,883 2,282 22,040 936 20 0.0000 Size of Child at Birth Very Large Larger than Average Average Smaller than Average Very Small 310 (7.17) 688 (7.39) 1,077 (8.39) 394 (11.82) 224 (15.8) 4,328 9,310 12,841 3,335 1,415 0.0000 Place of Delivery Home Hospital Other places 1,959 (9.76) 778 (6.83) 3 (8.63) 20,071 11,393 38 0.0000 Antenatal Visits No ANC 1 - 4 Visits More than 4 Visits 493 (7.05) 229 (5.55) 464 (4.97) 6,990 4,135 9,343 0.0000 Postnatal Visits No Visit Made Visit(s) 947 (6.51) 198 (3.41) 14,548 5,806 0.0000

Source: 2013 NDHS data

Factors influencing Child Mortality at Multivariate Level Table 3 below presents the effect of some socio-demographic and environmental factors at multivariate level on child mortality. From the findings, female children were found to be 15% less likely to die when compared with their male counterparts. Children of mothers aged 35-49 years were about 26% more likely to have died before age five than those from mothers aged 25- 34 years. Children of mothers with no and primary education were about 11% and 12% respectively more likely to die before age 5 than children whose mothers had secondary

• education. Children from rural areas were 16% more likely to die before attaining age 5 than

children from urban areas. Children from Richest wealth quintile were about 57% less likely to make their fifth birthday compared to those from poorest wealth quintile. In addition children from single-parent and monogamous families were 6% and 18% respectively less likely to die than children from polygamous families. On the effect of place of delivery on child mortality, children born at home and hospital were found to be 16% and 12% respectively less likely to die than those born in other places. In this study also, women using mosquito nets were also found to be 8% less likely to report child

• mortality. Children whose source of drinking water is rain were 63% less likely to attain their

fifth birthday than those who drank from other sources of water supply. Similarly children whose main source of drinking water is well water were about 40% less likely to die before age 5 than those drinking from other sources of water. In conclusion, wealth index, postnatal visits, source

• f water, monogamous family type and women aged 35-49 were found to be significantly

associated with child mortality in this study (Table 3).

Table 3: Multivariate Analysis: Factors influencing Child Mortality S

Source: 2013 NDHS data

Background Variable AOR 95% CI P-value Age of Mothers 25-34 15-24 35-49 RC 1.14 1.26

• 0.90-1.44

1.01-1.57

• 0.29

0.04 Mother‘s Educational Level Secondary None Primary Higher RC 1.11. 1.12 1.13

• .0.79-1.56

0.83-1.54 0.74-1.73

• 0.54

0.46 0.58 Family Type Polygamous Single-Parent Monogamous RC 0.94 0.82 0.65-1.36 0 .68-1.00 0.74 0.05 Place of Residence Urban Rural RC 1.16 0.93-1.46 0.20 Religion Traditionalists Christianity Islam RC 2.03 1.67 0 .59-6.95 0.49-5.66 0.26 0.41 Wealth Index Poorer Poorest Middle Richer Richest RC 0.94 0.63 0.64 0.43 0.75-1.18 0.48-0.83 0.46-0.89 0.27-0.70 0.62 0.00 0.01 0.00 Number

• f

Children Ever Born 1 or 2 Births 3 or 4 Births 5 births+ RC 0.60 0.82 0.47-0. 77 0.62-1.09 0.00 0.17 Sex of Child Male Female RC 0.85 0.73-1.00 0.06 ANC 1 - 4 Visits No ANC More than 4 Visits 0.90 0.93 0.72- 1.12

• .71- 1.18

0.34 0.57 Postnatal No Visit Have Visit(s) 0.529 0.41-0.68 0.00 Mosquito Nets Not Used Used RC 0.92 0.78-1.10 0 0.38 Wall Materials No wall Cane/Palm/Trunks/ Dirt Bamboo/Stone with Mud Cement Others RC 1.22 1.52 1.37 1.21 0.65-2.32 0.76-3.02 0.71-2.65 0.47-3.14 0.54 0.23 0.35 0.69 Source of Water Others Pipe/Tap/Bore Well Surface Rain RC 0 .72 0.59 0.75 0 .37 0.49-1.04 0.39-0.90 0.49-1.16 0.13-1.07 0.08 0.01 0.20 0.07 Toilet Facilities Shared Shared Not Shared RC 0.98 0.80-1.19 0.83 Stool Disposal Not Disposed Toilet Garbage Buried RC 0.40 034 0.49 0.07-2.18 0.06-1.77 0.09-2.66 0.29 0.20 0.41 Place of Delivery Other places Home Hospital RC 0.84 0.88 0 .10-6.79 0.11- 7.11 0.87 0.90

Discussion This study examined the position of environmental factors as predictors of childhood mortality in

• Nigeria. In the study, childhood mortality was found to be associated with mothers‘ age,

education, employment status, family type and location. Health and environmental factors such as place of delivery, toilet facility, source of drinking water, net usage, house roof, wall materials as well as antenatal and postnatal visits were also associated with child mortality. Women‘s age is a significant determinant of childhood mortality. The effect of water source is significant on child mortality in the study area with children who had access to clean water from taps, pipes and boreholes having higher likelihood of living beyond five years. Similarly, a child brought up in more hygienic condition (having good toilet facility and efficient refuse and excreta disposal) tend to survive child mortality than those who don‘t. In both rural and urban areas access to clean water and improved sanitation are some of the most important factors in human health. Over 1 billion people living in developing world live without portable water while some 3 million lack basic sanitation (Buckley, 2003, Balint, 1999). Victoria, Huttly, Fuchas & Olonto (1997) found access to piped water to significant in explaining infant death from diarrhea. The indirect link between poor water system and sanitation and mortality makes relationship between the two to be unclear. Esrey, Potash, Roberts & Shiff (1991) however stated that safe water is not sufficient in itself to reduce child mortality unless sanitation and hygienic practices are equally good. Environmental health factors play important role in child survival even when controlling for socio-economic variation (Anderson, Romani, Philips & van Zyl, 2002). Although difficult to decipher in empirical analyses, Rainham and McDowell (2005) found survival like all population health outcomes, are clearly linked to the environment. It may be difficult to ascertain the direct effect of environmental factors on health partly due to innumerable contamination routes and

• ver shadow of environmental factors by social and environmental factors after they have been

controlled for. Therefore, due to the inherent difficulty in measuring the effects of the environmental factors, well-defined and robust environmental health indicators are not widely available (Filmer & Prichett, 1999, Balint 1999 & Buckley 2003, Franz & Roy, 2006).

Child mortality decreased as the level of education attained by mothers‘ education increases. This finding is consistent with the report of study carried out by Balk, Pullum, Storeygard, Greenwell & Neuman in 2004. Parent‘s education significantly affects child mortality, this in agreement with report of Measure DHS 1997 that there was strong evidence concerning the positive impact of mother‘s education on child‘s health and survival. It is clear that there is generally a drop in infant and child mortality when the level of mother‘s education increases. There are strong inverse relationship between mother‘s education and child mortality, Groose & Auffery (1989) and Kost & Amin (1992). Similarly, child mortality reduced with higher education of respondents‘ partner, but mother‘s education has a greater influence on child survival in Bangladesh than that of father‘s education, Majumder & Islam (1992). A working parent will be able to provide for both materials and health needs of his/her children; this will contribute to the higher chance of the child surviving as identified in Majumder & Islam (1992), that mother-working status exerts a significant negative influence on child mortality. Despite the fact that a negative relationship was found between the working status of mothers and child mortality in this study, the effect was not statistically significant. Also, the family type that a woman belongs to also significantly influenced child mortality in the study area. The usual place of residence of respondents can also influence her health and that of her

• children. A significant relationship existed between place of residence and child mortality.

Children in rural areas had more likelihood of not attaining age five. This was also in consonance with the findings in Measure DHS 1997. We found that place of delivery has beneficial effect on child mortality. The risk of child mortality was lower for the children who were born at home and hospital compared to the children born elsewhere. Low birth weight has been identified as one of the risk factors of child mortality by some

• researchers. In this study, women that have children with very large size at birth reported lower

child mortality. Although malaria is one of the major causes of child mortality in countries with high mortality which could be prevented by the use of mosquito nets. In our study, mothers using

mosquito nets have less likelihood of reporting child mortality though the use of mosquito nets was not statistically significant to child mortality. Conclusion Child mortality prevalence is high in Nigeria, but there were variations across subgroup of women in the country. Among the environmental factors considered in this study, only source of drinking water was found among other predictors (age, wealth index, children ever born and post-natal visit) of childhood mortality in Nigeria. Source of drinking water should be considered important when designing strategies to reducing childhood mortality in Nigeria. References Anderson BA, Romani JH, Philips HE and van Zyl JA (2002) Environment, access to health care, and other factors affecting infant and child survival among the African and coloured populations of South Africa, 1989-94. Population and Environment, 23(4) Balk D, Pullum T, Storeygard A, Greenwell F and Neuman M (2004) A Spatial Analysis of Childhood Mortality in West Africa. Population, Space and Place 10: 175-216 Balint PJ (1999) Drinking water and sanitation in the developing world: the Miskito coast of Honduraus and Nicaraguas, a case study. Journal of Public and International Affairs, 10(1), 99-117 Buckley C (2003) Children at risk: infant and child health in Central Asia, William Davidson Working Paper, 523 Caldwell JC (1979) Education as a Factor in Mortality Decline: An Examination of Nigerian

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