Adult education and child mortality in India: the influence of caste, household wealth, and urbanization

Socioeconomic inequality in child health outcomes in India: analyzing trends between 1993 and 2021

BACKGROUND

The health of India's children has improved over the past thirty years. Rates of morbidity and anthropometric failure have decreased. What remains unknown, however, is how those patterns have changed when examined by socioeconomic status. We examine changes in 11 indicators of child health by household wealth and maternal education between 1993 and 2021 to fill this critical gap in knowledge. Doing so could lead to policies that better target the most vulnerable children.

METHODS

We used data from five rounds of India's National Family Health Survey conducted in 1993, 1999, 2006, 2016, and 2021 for this repeated cross-sectional analysis. We studied mother-reported cases of acute respiratory illness and diarrhea, hemoglobin measurements for anemia, and height and weight measurements for anthropometric failure. We examined how the prevalence rates of each outcome changed between 1993 and 2021 by household wealth and maternal education. We repeated this analysis for urban and rural communities.  RESULTS: The socioeconomic gradient in 11 indicators of child health flattened between 1993 and 2021. This was in large part due to large reductions in the prevalence among children in the lowest socioeconomic groups. For most outcomes, the largest reductions occurred before 2016. Yet as of 2021, except for mild anemia, outcome prevalence remained the highest among children in the lowest socioeconomic groups. Furthermore, we show that increases in the prevalence of stunting and wasting between 2016 and 2021 are largely driven by increases in the severe forms of these outcomes among children in the highest socioeconomic groups. This finding underscores the importance of examining child health outcomes by severity.

CONCLUSIONS

Despite substantial reductions in the socioeconomic gradient in 11 indicators of child health between 1993 and 2021, outcome prevalence remained the highest among children in the lowest socioeconomic groups in most cases. Thus, our findings emphasize the need for a continued focus on India's most vulnerable children.

Linkages of Multi-Dimensional Vulnerabilities with Infant and Child Mortality Rates in India and Its Specific Regions: Are Social Determinants of Health still Relevant?

The present study investigated linkages between multiple socio-economic vulnerabilities with infant and child mortality in India and its specific regions. Data from the National Family Health Survey (2015-16) was used for calculating the key-outcome variables, namely infant mortality and child mortality. The effective sample size for the study was 259,627. Bivariate analysis and binary logistic regression analysis were employed to examine three dimensions of vulnerabilities such as education, wealth, and caste on infant and child mortality. Children born to women with multiple-vulnerabilities were more likely to die than those born to non-vulnerable women. Women who were vulnerable in all the three-dimensions were more likely to have their children die as infants than those who were not vulnerable in any dimensions (predicted probabilities; 0.054 vs 0.026). The predicted probability for child mortality was 0.063 for women who were vulnerable and 0.028 for non-vulnerable women.

Explaining the diminishing of Muslim advantage in child survival in India

Religion is one of the key instrumental social institutions in determining child health and mortality. Muslim advantage in child survival in India has been widely reported. Recent India’s National Family Health Survey (NFHS) shows that the gap between Hindu–Muslim childhood mortality rates is shrinking—reversing decades of child survival advantage for Muslims. This study examines the factors linked to the diminishing of Muslim advantage in childhood survival and attempts to uncover the mechanisms accounting for the convergence using the characteristics hypothesis of Goldscheider (Population, modernization, and social structure Little, Brown & Co; 1971) and the analytical framework of Guillot and Allendorf (Genus 66(2), 2010). We have analyzed a pooled sample of 23,47,245 all live births and 428,541 of last live births from four rounds of NFHS (1992–2016). Kaplan–Meier survival plots over time by religion confirm convergence in Hindu–Muslim child survival probabilities. The Pyatt decomposition model reveals that the gap in Hindu–Muslim childhood mortality is diminishing due to a decline in within-Hindu inequality. Cox proportional hazard regression model shows that improvement in household and maternal socioeconomic factors has contributed to Hindu children catching up with Muslims—leading to a convergence in Hindu–Muslim childhood survival probabilities. Conditional β-convergence regression model also suggests the convergence in socio-economic status and maternal health care is driving the convergence in child survival of Hindus and Muslims across Indian states.

Health equity impact of community-initiated kangaroo mother care: a randomized controlled trial

BACKGROUND

Kangaroo mother care (KMC) can substantially enhance overall survival of low birthweight babies. In a large randomized controlled trial, we recently showed that supporting mothers to provide community initiated KMC (ciKMC) can reduce mortality among infants up to 180 days of life by 25% (hazard ratio (HR) 0.75). With the current analysis, we aimed to explore if ciKMC promotion leads to increased inequity in survival.

METHODS

In the trial we randomized 8402 low birthweight babies to a ciKMC (4480 babies) and a control (3922 babies) arm, between 2015 and 2018 in Haryana, India. We estimated the difference in concentration indices, which measure inequality, between babies in the ciKMC and control arms for survival until 180 days of life. Further, we compared the effect of ciKMC promotion across subgroups defined by socioeconomic status, caste, maternal literacy, infant's sex, and religion.

RESULTS

Our intervention did not increase survival inequity, as the concentration index in the ciKMC arm of the trial was 0.05 (95% CI -0.07 to 0.17) lower than in the control arm. Survival impact was higher among those belonging to the lower two wealth quintiles, those born to illiterate mothers and those belonging to religions other than Hindu.

CONCLUSIONS

We found that ciKMC promotion did not increase inequity in survival associated with wealth. The beneficial impact of ciKMC tended to be larger among vulnerable groups. Supporting mothers to provide KMC at home to low birthweight babies will not increase and could indeed reduce inequities in infant survival.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02653534 . Registered January 12, 2016-Retrospectively registered.

Closing the gap on institutional delivery in northern India: a case study of how integrated machine learning approaches can enable precision public health

INTRODUCTION

Meeting ambitious global health goals with limited resources requires a precision public health (PxPH) approach. Here we describe how integrating data collection optimisation, traditional analytics and causal artificial intelligence/machine learning (ML) can be used in a use case for increasing hospital deliveries of newborns in Uttar Pradesh, India.

METHODS

Using a systematic behavioural framework we designed a large-scale survey on perceptual, interpersonal and structural drivers of women's behaviour around childbirth (n=5613). Multivariate logistic regression identified factors associated with institutional delivery (ID). Causal ML determined the cause-and-effect ordering of these factors. Variance decomposition was used to parse sources of variation in delivery location, and a supervised learning algorithm was used to distinguish population subgroups.

RESULTS

Among the factors found associated with ID, the causal model showed that having a delivery plan (OR=6.1, 95% CI 6.0 to 6.3), believing the hospital is safer than home (OR=5.4, 95% CI 5.1 to 5.6) and awareness of financial incentives were direct causes of ID (OR=3.4, 95% CI 3.3 to 3.5). Distance to the hospital, borrowing delivery money and the primary decision-maker were not causal. Individual-level factors contributed 69% of variance in delivery location. The segmentation analysis showed four distinct subgroups differentiated by ID risk perception, parity and planning.

CONCLUSION

These findings generate a holistic picture of the drivers and barriers to ID in Uttar Pradesh and suggest distinct intervention points for different women. This demonstrates data optimised to identify key behavioural drivers, coupled with traditional and ML analytics, can help design a PxPH approach that maximise the impact of limited resources.

Factors explaining regional variation in under-five mortality in India: An evidence from NFHS-4

Although child mortality has declined in India, pronounced regional and socioeconomic inequality exists. The study examines the effects of individual- and community-level characteristics on under-five mortality and investigates the extent to which they affect regional variation. The study is based on Indian National Family and Health Survey 4, 2015-16 data. A two-level logistic regression model was performed to examine the effects of the socio-economic characteristics, and multivariate decomposition analysis was done to assess the contribution of factors in the inter-regional under-five mortality differentials. Regional variation in the selected variables is observed. For instance, the percentage of children with small childbirth size varied from 9.7% in the southern to 21.6% in the northeastern region. The percentage of poor households, low educated mothers, and childbirths delivered at home facility were higher in the central and eastern region compared to the southern region. The multilevel analysis shows that the region of residence explained 15.8% variance, and community-level characteristics alone could explain 25.3% variation in the risk of under-five deaths. The decomposition analysis indicates that the average number of excess deaths in the central and eastern regions is higher compared to the other regions. The compositional differences account for 50.9% of the under-five mortality gaps between the south and north region, 80.9% of the gap between the south and east, and 42.9% of the gap between the south and central region of India. Special attention and targeted action are needed to address the underlying causes of low birth weight of children in all the regions of India. Region-specific interventions might be priorities; for example, north, and central regions, need an economic and educational uplift, while infrastructural and economic policies should be prioritized for the northeastern region. Also, region-specific community-level interventions are needed to improve child survival in India.

Effect of caste on health, independent of economic disparity: evidence from school children of two rural districts of India

Caste, a stratifying axis of the Indian society, is associated with wealth and health. However, to what extent caste-based health inequality is explained by wealth disparities, is not clear. Therefore, we aimed to examine the caste-based differences in anaemia (haemoglobin < 11 gm/dl) and self-reported sickness absenteeism in schoolchildren and the mediating role of economic disparity. Students (n = 1764) were surveyed from 54 government schools of Dhenkanal and Angul, Odisha state. Socioeconomic data, anaemia and absenteeism were recorded. The relative risks of anaemia among Scheduled Tribe (least advantaged) and Scheduled Caste (second least advantaged) students were 1.19 (95% CI: 1.08, 1.26) and 1.13 (1.03, 1.20), respectively, as compared to students of the most advantaged caste and that for sickness absenteeism were 2.78 (2.03, 3.82) and 2.84 (2.13, 3.78); p < 0.05, with marginal attenuation when controlled for inter-caste economic disparities. Caste had an independent effect on anaemia and sickness absenteeism in school children, unexplained by inter-caste economic disparities.

The persistent influence of caste on under-five mortality: Factors that explain the caste-based gap in high focus Indian states

OBJECTIVE

Although under-five mortality rate (U5MR) is declining in India, it is still high in a few selected states and among the scheduled caste (SC) and scheduled tribe (ST) population of the country. This study re-examines the association between caste and under-five deaths in high focus Indian states following the implementation of the country's National Rural Health Mission (NRHM) program. In addition, we aim to quantify the contribution of socioeconomic determinants in explaining the gap in under-five death risk between the SC/ST population and non-SC/ST population in high focus states in India.

DATA AND METHOD

Using data from the National Family Health Survey (NFHS), we calculated the U5MR by applying a synthetic cohort probability approach. We applied a binary logistic regression model to examine the association of under-five deaths with the selected covariates. Further, we used Fairlie's decomposition technique to understand the relative contribution of socioeconomic variables on under-five death risk between the caste groups.

FINDINGS

In high focus Indian states, the under-five mortality risk between well-off and deprived caste children has declined in the post-NRHM period, indicating a positive impact in terms of reducing caste-based inequalities in the high focus states. Despite the reduction in under-five death risk, children belonging to the SC population experience higher mortality rates than children belonging to the non-SC/ST population from 1992 to 2016. Both macro level (district level mortality rates) and individual (regression analysis) analyses showed that children belonging to SCs experience the highest likelihood of dying before their fifth birthday. A decomposition analysis revealed that 83% of the caste-based gap in the under-five deaths is due to the distribution of women's level of educational attainment and household wealth between the SC/ST and non-SC/ST population. Program indicators such as place of birth and number of antenatal care (ANC) visit also contributed significantly to widening caste-based gaps in U5MR.

CONCLUSION

The study indicates that there is still room to improve access to health facilities for mothers and children belonging to deprived caste groups in India. Continuous efforts to raise the level of maternal education and the economic status of people belonging to deprived caste groups should be pursued simultaneously.

Socioeconomic and gender inequalities in neonatal, postneonatal and child mortality in India: a repeated cross-sectional study, 2005-2016

BACKGROUND

In India, excess female under-5 mortality is well documented. Under-5 mortality is also known to be patterned by socioeconomic factors. This study examines sex differentials and sex-specific wealth gradients in neonatal, postneonatal and child mortality in India.

METHODS

Repeated cross-sectional study of nationally representative samples of 298 955 children 0-60 months old from the National Family Health Surveys conducted in 2005-2006 and 2015-2016. The study used logistic regression models as well as Cox proportional hazards models.

RESULTS

Overall, boys had greater neonatal mortality than girls and the difference increased between 2005-2006 and 2015-2016. Girls had greater postneonatal and child mortality, but the difference decreased between the surveys and was not statistically significant for child mortality in 2015-2016. A negative wealth gradient was found for all mortality outcomes. Neonatal mortality was persistently greater for boys. Girls had higher child mortality than boys at low levels of wealth and greater postneonatal mortality over much of the wealth distribution. The wealth gradient in neonatal mortality increased between surveys. Females had a stronger wealth gradient than boys for child mortality.

CONCLUSION

Not distinguishing between neonatal, postneonatal and child mortality masks important gender-specific and wealth-specific disparities in under-5 mortality in India. Substantial gains towards the Sustainable Development Goals can be made by combating neonatal mortality, especially at low levels of wealth. Although impressive improvements have been made in reducing the female disadvantage in postneonatal and child mortality, concerted engagements are necessary to eliminate the gender gap-especially in poor households and in north India.

Causes of and contributors to infant mortality in a rural community of North India: evidence from verbal and social autopsy

OBJECTIVE

To identify the medical causes of death and contribution of non-biological factors towards infant mortality by a retrospective analysis of routinely collected data using verbal and social autopsy tools.

SETTING

The study site was Health and Demographic Surveillance System (HDSS), Ballabgarh, North India PARTICIPANTS: All infant deaths during the years 2008-2012 were included for verbal autopsy and infant deaths from July 2012 to December 2012 were included for social autopsy.

OUTCOME MEASURES

Cause of death ascertained by a validated verbal autopsy tool and level of delay based on a three-delay model using the INDEPTH social autopsy tool were the main outcome measures. The level of delay was defined as follows: level 1, delay in identification of danger signs and decision making to seek care; level 2, delay in reaching a health facility from home; level 3, delay in getting healthcare at the health facility.

RESULTS

The infant mortality rate during the study period was 46.5/1000 live births. Neonatal deaths contributed to 54.3% of infant deaths and 39% occurred on the first day of life. Birth asphyxia (31.5%) followed by low birth weight (LBW)/prematurity (26.5%) were the most common causes of neonatal death, while infection (57.8%) was the most common cause of post-neonatal death. Care-seeking was delayed among 50% of neonatal deaths and 41.2% of post-neonatal deaths. Delay at level 1 was most common and occurred in 32.4% of neonatal deaths and 29.4% of post-neonatal deaths. Deaths due to LBW/prematurity were mostly followed by delay at level 1.

CONCLUSION

A high proportion of preventable infant mortality still exists in an area which is under continuous health and demographic surveillance. There is a need to enhance home-based preventive care to enable the mother to identify and respond to danger signs. Verbal autopsy and social autopsy could be routinely done to guide policy interventions aimed at reduction of infant mortality.

Caste-based social inequalities and childhood anemia in India: results from the National Family Health Survey (NFHS) 2005-2006

Background

Caste is one of the traditional measures of social segregation in India and differs from other indicators as it is both, endogamous and hereditary. Evidence suggests that belonging to lower castes exposes one to social inequalities and affects health adversely. We examined the association of caste with childhood anemia in India and explored the effect modifying role of adult education and household wealth.

Methods

A cross-sectional analysis of National Family Health Survey (NFHS) data of 43,484 children aged 6–59 months was performed. Poisson regression analysis was conducted to study the association between caste and childhood anemia accounting for various maternal, child, and household related variables. Caste was categorized as “other caste” (least disadvantageous), “other backward caste”, “scheduled tribe” and “scheduled caste” (most disadvantageous). Anemia was defined as mild (hemoglobin level 7-11 g/dL), moderate (hemoglobin level 5-7 g/dL) and severe (hemoglobin level <5 g/dL).

Results

We found that children in scheduled caste had higher risk of having anemia [mild anemia: RR = 1.10, 95 % CI = 1.05-1.15; moderate anemia: RR = 1.19, 95 % CI = 1.14–1.24; severe anemia: RR = 1.87, 95 % CI = 1.51 – 2.31] after accounting for child, maternal and household covariates including adult education and household wealth. The interaction of caste with adult education and household wealth was not statistically significant for any level of anemia. Sensitivity analyses for children born to mothers of age ≥ 18 years at first child birth and body mass index (BMI) ≥ 18.5 kg/m², resulted in similar findings.

Conclusion

Caste is an independent determinant of childhood anemia in India. The level of adult education and household wealth did not modify the association between caste and childhood anemia. The findings may be used for countering childhood anemia and it may be beneficial to target future public health actions towards disadvantageous castes in India.

Education is associated with lower levels of abdominal obesity in women with a non-agricultural occupation: an interaction study using China's Four Provinces survey

Background

The prevalence of obesity is increasing rapidly in low- and middle-income countries (LMICs) as their populations become exposed to obesogenic environments. The transition from an agrarian to an industrial and service-based economy results in important lifestyle changes. Yet different socioeconomic groups may experience and respond to these changes differently. Investigating the socioeconomic distribution of obesity in LMICs is key to understanding the causes of obesity but the field is limited by the scarcity of data and a uni-dimensional approach to socioeconomic status (SES). This study splits socioeconomic status into two dimensions to investigate how educated women may have lower levels of obesity in a context where labour market opportunities have shifted away from agriculture to other forms of employment.

Methods

The Four Provinces Study in China 2008/09 is a household-based community survey of 4,314 people aged ≥60  years (2,465 women). It was used to investigate an interaction between education (none/any) and occupation (agricultural/non-agricultural) on high-risk central obesity defined as a waist circumference ≥80 cm. An interaction term between education and occupation was incorporated in a multivariate logistic regression model, and the estimates adjusted for age, parity, urban/rural residence and health behaviours (smoking, alcohol, meat and fruit & vegetable consumption). Complete case analyses were undertaken and results confirmed using multiple imputation to impute missing data.

Results

An interaction between occupation and education was present (P = 0.02). In the group with no education, the odds of central obesity in the sedentary occupation group were more than double those of the agricultural occupation group even after taking age group and parity into account (OR; 95%CI: 2.21; 1.52, 3.21), while in the group with any education there was no evidence of such a relationship (OR; 95%CI: 1.25; 0.92, 1.70). Health behaviours appeared to account for some of the association.

Conclusion

These findings suggest that education may have a protective role in women against the higher odds of obesity associated with occupational shifts in middle-income countries, and that investment in women’s education may present an important long term investment in obesity prevention. Further research could elucidate the mechanisms behind this association.

Measuring socio-economic position for epidemiological studies in low- and middle-income countries: a methods of measurement in epidemiology paper

Much has been written about the measurement of socio-economic position (SEP) in high-income countries (HIC). Less has been written for an epidemiology, health systems and public health audience about the measurement of SEP in low- and middle-income countries (LMIC). The social stratification processes in many LMIC-and therefore the appropriate measurement tools-differ considerably from those in HIC. Many measures of SEP have been utilized in epidemiological studies; the aspects of SEP captured by these measures and the pathways through which they may affect health are likely to be slightly different but overlapping. No single measure of SEP will be ideal for all studies and contexts; the strengths and limitations of a given indicator are likely to vary according to the specific research question. Understanding the general properties of different indicators, however, is essential for all those involved in the design or interpretation of epidemiological studies. In this article, we describe the measures of SEP used in LMIC. We concentrate on measures of individual or household-level SEP rather than area-based or ecological measures such as gross domestic product. We describe each indicator in terms of its theoretical basis, interpretation, measurement, strengths and limitations. We also provide brief comparisons between LMIC and HIC for each measure.

Child mortality in India: a complex situation

BACKGROUND

The countdown database to track the maternal and child survival rate, as set by the Millennium Development Goal, reported recently that India's progress is not satisfactory in reducing newborn and child deaths.

DATA SOURCES

Articles on neonatal and child mortality in India were accessed from PubMed/MEDLINE. Risk factors associated with neonatal and child mortality were reviewed in three crucial phases of pregnancy, childbirth and postnatal period.

RESULTS

The review revealed economic disparity acts through various avenues of cultural belief and restrictions and is indirectly associated with care seeking behavior and utilization of health care, resulting in slow decline of child mortality rate in India. Secondly, cultural norms, practices, and beliefs are strongly associated with high neonatal mortality, contributing to the sluggish decline of overall child survival rate. Proximate determinants of child mortality, i.e., income, cultural behavior and beliefs, in multiplicity of Indian cultures, are closely associated with health seeking behavior, antenatal care, delivery practices and postnatal care of infants.

CONCLUSIONS

Apart from raising awareness among community leaders, family members responsible for care giving should be specially targeted for removal of hostile perceptions and barriers for improvement of child survival. Also there is need for developing new strategies for health education based on indigenous concerns, addressing socio-cultural barriers.

Influence of temperature on the emission of di-(2-ethylhexyl)phthalate (DEHP) from PVC flooring in the emission cell FLEC

Emissions of di-(2-ethylhexyl) phthalate (DEHP) from one type of polyvinylchloride (PVC) flooring with approximately 13% (w/w) DEHP as plasticizer were measured in the Field and Laboratory Emission Cell (FLEC). The gas-phase concentrations of DEHP versus time were measured at air flow rate of 450 mL·min(-1) and five different temperatures: 23 °C, 35 °C, 47 °C, 55 °C, and 61 °C. The experiments were terminated two weeks to three months after steady-state was reached and the interior surface of the FLECs was rinsed with methanol to determine the surface concentration of DEHP. The most important findings are (1) DEHP steady-state concentrations increased greatly with increasing temperature (0.9 ± 0.1 μg·m(-3), 10 ± 1 μg·m(-3), 38 ± 1 μg·m(-3), 91 ± 4 μg·m(-3), and 198 ± 5 μg·m(-3), respectively), (2) adsorption to the chamber walls decreased greatly with increasing temperature (measured partition coefficient between FLEC air and interior surface are: 640 ± 146 m, 97 ± 20 m, 21 ± 5 m, 11 ± 2 m, and 2 ± 1 m, respectively), (3) gas-phase DEHP concentration in equilibrium with the vinyl flooring surface is close to the vapor pressure of pure DEHP, and (4) with an increase of temperature in a home from 23 to 35 °C, the amount of DEHP in the gas- and particle-phase combined is predicted to increase almost 10-fold. The amount in the gas-phase increases by a factor of 24 with a corresponding decrease in the amount on the airborne particles.

Infant and child mortality in India in the last two decades: a geospatial analysis

Background

Studies examining the intricate interplay between poverty, female literacy, child malnutrition, and child mortality are rare in demographic literature. Given the recent focus on Millennium Development Goals 4 (child survival) and 5 (maternal health), we explored whether the geographic regions that were underprivileged in terms of wealth, female literacy, child nutrition, or safe delivery were also grappling with the elevated risk of child mortality; whether there were any spatial outliers; whether these relationships have undergone any significant change over historical time periods.

Methodology

The present paper attempted to investigate these critical questions using data from household surveys like NFHS 1992–1993, NFHS 1998–1999 and DLHS 2002–2004. For the first time, we employed geo-spatial techniques like Moran's-I, univariate LISA, bivariate LISA, spatial error regression, and spatiotemporal regression to address the research problem. For carrying out the geospatial analysis, we classified India into 76 natural regions based on the agro-climatic scheme proposed by Bhat and Zavier (1999) following the Census of India Study and all estimates were generated for each of the geographic regions.

Result/Conclusions

This study brings out the stark intra-state and inter-regional disparities in infant and under-five mortality in India over the past two decades. It further reveals, for the first time, that geographic regions that were underprivileged in child nutrition or wealth or female literacy were also likely to be disadvantaged in terms of infant and child survival irrespective of the state to which they belong. While the role of economic status in explaining child malnutrition and child survival has weakened, the effect of mother's education has actually become stronger over time.

Health systems performance in sub-Saharan Africa: governance, outcome and equity

BACKGROUND

The literature on health systems focuses largely on the performance of healthcare systems operationalised around indicators such as hospital beds, maternity care and immunisation coverage. A broader definition of health systems however, needs to include the wider determinants of health including, possibly, governance and its relationship to health and health equity. The aim of this study was to examine the relationship between health systems outcomes and equity, and governance as a part of a process to extend the range of indicators used to assess health systems performance.

METHODS

Using cross sectional data from 46 countries in the African region of the World Health Organization, an ecological analysis was conducted to examine the relationship between governance and health systems performance. The data were analysed using multiple linear regression and a standard progressive modelling procedure. The under-five mortality rate (U5MR) was used as the health outcome measure and the ratio of U5MR in the wealthiest and poorest quintiles was used as the measure of health equity. Governance was measured using two contextually relevant indices developed by the Mo Ibrahim Foundation.

RESULTS

Governance was strongly associated with U5MR and moderately associated with the U5MR quintile ratio. After controlling for possible confounding by healthcare, finance, education, and water and sanitation, governance remained significantly associated with U5MR. Governance was not, however, significantly associated with equity in U5MR outcomes.

CONCLUSION

This study suggests that the quality of governance may be an important structural determinant of health systems performance, and could be an indicator to be monitored. The association suggests there might be a causal relationship. However, the cross-sectional design, the level of missing data, and the small sample size, forces tentative conclusions. Further research will be needed to assess the causal relationship, and its generalizability beyond U5MR as a health outcome measure, as well as the geographical generalizability of the results.

Mortality burden and socioeconomic status in India

Background

The dimensions along which mortality is patterned in India remains unclear. We examined the specific contribution of social castes, household income, assets, and monthly per capita consumption to mortality differentials in India.

Methods and Findings

Cross-sectional data on 217 363 individuals from 41 554 households from the 2004–2005 India Human Development Survey was analyzed using multiple logistic regressions. Mortality differentials across social castes were attenuated after adjusting for household economic factors such as income and assets. Individuals living in the lowest income and assets quintiles had an increased risk of mortality with odds ratio (OR) of 1.66 (95% CI  = 1.23–2.24) in the bottom income quintile and OR of 2.94 (95% CI  = 1.66–5.22) in the bottom asset quintile. Counter-intuitively, individuals living in households with lowest monthly consumption per capita had significantly lower probability of death (OR  = 0.27, 95% CI  = 0.20–0.38).

Conclusions

Mortality burden in India is largely patterned on economic dimensions as opposed to caste dimensions, though caste may play an important role in predicting economic opportunities.

Socio-economic inequalities in childhood mortality in low- and middle-income countries: a review of the international evidence

INTRODUCTION

In low- and middle-income countries (LMICs), the probability of dying in childhood is strongly related to the socio-economic position of the parents or household in which the child is born. This article reviews the evidence on the magnitude of socio-economic inequalities in childhood mortality within LMICs, discusses possible causes and highlights entry points for intervention. Sources of data Evidence on socio-economic inequalities in childhood mortality in LMICs is mostly based on data from household surveys and demographic surveillance sites.

AREAS OF AGREEMENT

Childhood mortality is systematically and considerably higher among lower socio-economic groups within countries. Also most proximate mortality determinants, including malnutrition, exposure to infections, maternal characteristics and health care use show worse levels among more deprived groups. The magnitude of inequality varies between countries and over time, suggesting its amenability to intervention. Reducing inequalities in childhood mortality would substantially contribute to improving population health and reaching the Millennium Development Goals (MDGs).

AREAS OF CONTROVERSY

The contribution of specific determinants, including national policies, to childhood mortality inequalities remains uncertain. What works to reduce these inequalities, in particular whether policies should be universal or targeted to the poor, is much debated.

AREAS TIMELY FOR DEVELOPING RESEARCH

The increasing political attention for addressing health inequalities needs to be accompanied by more evidence on the contribution of specific determinants, and on ways to ensure that interventions reach lower socio-economic groups.

Intimate partner violence and death among infants and children in India

OBJECTIVE

The goal was to test the association between maternal intimate partner violence (IPV) victimization and child death.

METHODS

Information was collected regarding 39096 children <60 months of age in the nationally representative 2005-2006 National Family Health Survey of India. The exposures were maternal reports of physical, sexual, psychological, and any IPV. Outcomes included infant (0 to <12 months), older child (12 to <60 months), and any child (0 to <60 months) deaths.

RESULTS

Maternal experience of physical IPV was associated with increased mortality rates among all children (risk ratio [RR]: 1.21 [95% confidence interval [CI]: 1.13-1.30]), infants (RR: 1.24 [95% CI: 1.01-1.53]), and older children (RR: 1.25 [95% CI: 1.00-1.56]). Sexual and psychological IPV were less strongly associated with child death. The associations between maternal IPV and death did not differ according to the child's gender.

CONCLUSION

The robust association between exposure to household IPV and infant and child death could be attributable to the mother's inability to care for her child, psychological stress associated with witnessing violence, and the use of maternal violence victimization as a proxy for child violence victimization.