Is there any association between parental education and child mortality? A study in a rural area of Bangladesh.

OBJECTIVES: To assess the association between parental education and under-five mortality, using the Integrated Management of Childhood Illness (IMCI) data from rural Bangladesh. It also investigated whether the association of parental education with under-five mortality had changed over time. STUDY DESIGN: This study was nested in the IMCI cluster randomized controlled trial. METHODS: Participants considered for the analysis were all children aged under five years from the baseline (1995-2000) and the final (2002-2007) IMCI household survey. The analysis sample included 39,875 and 38,544 live births from the baseline and the final survey respectively. The outcome variable was under-five mortality and the exposure variables were mother's and father's education. Data were analysed with logistic regression. RESULTS: In 2002-2007, the odds of the under-five mortality were 38% lower for the children with mother having secondary education, compared to the children with uneducated mother. For similar educational differences for fathers, at the same time period, the odds of the under-five mortality were 16% lower. The association of mother's education with under-five mortality was significantly stronger in 2002-2007 compared to 1995-2000. CONCLUSIONS: Mother's education appears to have a strong and significant association with under-five mortality, compared to father's education. The association of mother's education with under-five mortality appears to have increased over time. Our findings indicate that investing on girls' education is a good strategy to combat infant mortality in developing countries.

Sex and socioeconomic differentials in child health in rural Bangladesh: findings from a baseline survey for evaluating Integrated Management of Childhood Illness.

This paper reports on a population-based sample survey of 2,289 children aged less than five years (under-five children) conducted in 2000 as a baseline for the Bangladesh component of the Multi-country Evaluation (MCE) of the Integrated Management of Childhood Illness strategy. Of interest were rates and differentials by sex and socioeconomic status for three aspects of child health in rural Bangladesh: morbidity and hospitalizations, including severity of illness; care-seeking for childhood illness; and home-care for illness. The survey was carried out among a population of about 380,000 in Matlab upazila (subdistrict). Generic MCE Household Survey tools were adapted, translated, and pretested. Trained interviewers conducted the survey in the study areas. In total, 2,289 under-five children were included in the survey. Results showed a very high prevalence of illness among Bangladeshi children, with over two-thirds reported to have had at least one illness during the two weeks preceding the survey. Most sick children in this population had multiple symptoms, suggesting that the use of the IMCI clinical guidelines will lead to improved quality of care. Contrary to expectations, there were no significant differences in the prevalence of illness either by sex or by socioeconomic status. About one-third of the children with a reported illness did not receive any care outside the home. Of those for whom outside care was sought, 42% were taken to a village doctor. Only 8% were taken to an appropriate provider, i.e. a health facility, a hospital, a doctor, a paramedic, or a community-based health worker. Poorer children than less-poor children were less likely to be taken to an appropriate healthcare provider. The findings indicated that children with severe illness in the least poor households were three times more likely to seek care from a trained provider than children in the poorest households. Any evidence of gender inequities in child healthcare, either in terms of prevalence of illness or care-seeking patterns, was not found. Care-seeking patterns were associated with the perceived severity of illness, the presence of danger signs, and the duration and number of symptoms. The results highlight the challenges that will need to be addressed as IMCI is implemented in health facilities and extended to address key family and community practices, including extremely low rates of use of the formal health sector for the management of sick children. Child health planners and researchers must find ways to address the apparent population preference for untrained and traditional providers which is determined by various factors, including the actual and perceived quality of care, and the differentials in care-seeking practices that discriminate against the poorest households.

Quality of care for under-fives in first-level health facilities in one district of Bangladesh.

OBJECTIVE: The multi-country evaluation of Integrated Management of Childhood Illness (IMCI) effectiveness, cost and impact (MCE) is a global evaluation to determine the impact of IMCI on health outcomes and its cost-effectiveness. MCE studies are under way in Bangladesh, Brazil, Peru, Uganda and the United Republic of Tanzania. The objective of this analysis from the Bangladesh MCE study was to describe the quality of care delivered to sick children under 5 years old in first-level government health facilities, to inform government planning of child health programmes. METHODS: Generic MCE Health Facility Survey tools were adapted, translated and pre-tested. Medical doctors trained in IMCI and these tools conducted the survey in all 19 health facilities in the study areas. The data were collected using observations, exit interviews, inventories and interviews with facility providers. FINDINGS: Few of the sick children seeking care at these facilities were fully assessed or correctly treated, and almost none of their caregivers were advised on how to continue the care of the child at home. Over one-third of the sick children whose care was observed were managed by lower-level workers who were significantly more likely than higher-level workers to classify the sick child correctly and to provide correct information on home care to the caregiver. CONCLUSION: These results demonstrate an urgent need for interventions to improve the quality of care provided for sick children in first-level facilities in Bangladesh, and suggest that including lower-level workers as targets for IMCI case-management training may be beneficial. The findings suggest that the IMCI strategy offers a promising set of interventions to address the child health service problems in Bangladesh.