Maternal Education as a Strategy for Children's Survival and Health in Developing Countries, with Special Reference to Bangladesh
- Wardatul Akmam
Institute of Agricultural and Forest Engineering
University of Tsukuba, Tsukuba Science City 305-8572, Japan
Eubios Journal of Asian and International Bioethics 11 (2001), 76-78.
Socio-economic factors like income, occupation, education and social class are often mentioned as important factors in influencing perceptions, which determine people's health behaviour and illness behaviour (1). The present paper is related to education, more specifically, mothers' education. In this paper, I examine, on the basis of some studies carried out on the maternal-education and child survival /health relationship in developing countries, the following issues: (a) the extent to which the function of maternal education can be attributed to the overall socioeconomic condition, (b) the mechanisms through which maternal education can help reduce child mortality, (c) relative importance of general education and health education for children's survival/health and (d) maternal education as a strategy for children's survival/health. As the author is a citizen of Bangladesh, more references have been made to the studies carried out in the context of Bangladesh. The suggestions for interventions are also made with the context of Bangladesh society in mind.
Many studies have been carried out which recognize education (especially that of mothers) as an effective way of improving children's health and reducing mortality (1-8). Caldwell (9) refers to the results of two surveys that were carried out in Nigeria to arrive at the conclusion that "Maternal education is the single most significant determinant of child mortality." However, maternal education is an intertwined factor, and hence may account for other variables that represent socio-economic conditions as well.
Socioeconomic Condition and Maternal Education
It is often surmised that [see (3-10)] it is a universal tendency for educated women to get married to similarly educated men who enjoy higher standards of living. Cleland and van Ginneken (3) summarized, after controlling for dwelling and household economic characteristics, individual studies in which "the maternal education - mortality relationship" was analyzed. The result was that "usually the effect of education remains statistically significant" even after controlling for household economic characteristics. The authors broadly concluded that "the economic advantages associated with education (income, water and latrine facilities, clothing, housing quality etc.) probably accounts for about one-half of the overall education-mortality association" (p.1360). From the data of the 17 countries, Bicego and Boerma (6) conclude that a lower level of maternal education can significantly elevate the risks of child mortality with the risk of post neonatal mortality being twice as sensitive than neonatal mortality to the effect maternal education, even after controlling for household economic status. Moreover studies by Mahalanabis and other authors (8), and Guldan and other authors [(11) P: 932] also prove that even though maternal education is indeed very much intertwined with overall socio-economic status, it does have a perpetuating effect on the survival of children in Bangladesh, if not equally significant in other developing countries.
Although the relationship between maternal education and children's health is no longer an issue to be debated, there still exists a dearth of research information on the mechanisms through which maternal education works to improve children's health. A few of the possible mechanisms that have been focused so far are pointed out below:
(1) Education makes a woman conscious about the well being of herself and her family. It gives the basic ideas about the path to well being and also equips and encourages to increase her knowledge on healthy living;
(2) Education helps to form the attitude to practice "manners of hygiene" (3, 10-11);
(3) Education equips mothers with the knowledge of scientific causes of disease and proper health behaviour and illness behaviour for preventive and curative measures (9);
(4) Education encourages mothers to adopt proper feeding practices (11);
(5) Education makes the mothers more willing to use health care services when necessary [(3), (6)], and preparing them for overcoming the barriers in doing so (10). Doctors and nurses are more likely to listen to her, as she can demand their attention, whereas the illiterate might be completely rebuffed (19);
(6) Education allows greater exposure to the mass media, which can keep mothers better informed about the health issues (10);
(7) Education empowers mothers to make and implement proper and timely decisions regarding their children's health (3, 6, 9-11).
Thus, we find maternal education as a gate way toward diversified aspects of modern life that significantly affect children's morbidity and mortality.
General Education and Health Education
A debate has arisen on the link between maternal education and children's health concerns relative effectiveness of general education (acquired through formal schooling) and health education. While the former enables a mother to become literate and hence gain access to the understanding of written material, the latter only provides her with information on certain health issues. However, educating through general education is time consuming, and to get positive results for the improvement of the health of the illiterate masses, within a short time, health education might be a better choice.
Realizing that the risk of morbidity and mortality in rural Bangladesh is linked to a great extent with poverty and maternal education, CARE, Bangladesh arranged Women's Health Education Program (WHE) for the women in Rural Maintenance Program (RMP), who represented the poorest and mostly illiterate families and are harder hit by disease and death. CARE designed health education sessions that addressed general nutrition, Vitamin A deficiency/night blindness, breast feeding and food for weaning, diarrhoeal diseases and procedure of preparing Oral Re-hydration Solution (ORS), head lice, scabies, tetanus, intestinal worms, management of high fever, heat stroke, first aid, family planning and "familiarization with local health services" [(12) P:960]. The program emphasized preventive measures and encouraged home-based, local, traditional remedies for certain diseases like worms, scabies or head lice. The RMP women were also instructed about the time when they should consult a doctor and informed them about the available health services within their region. The WHE relied on visual aids and pictorial handouts to convey the health messages to the illiterate women. The health educators demonstrated the health care treatments and made each participant practice the learned skills in front of the instructor and the class so that their mistakes could be corrected. In three months, the women learned 97% of the course material. Their retention was evaluated six months later revealing that the mean overall scores dropped by about five percent. The RMP women who received WHE were asked to pass on the lessons they learned to at least two neighbours or relatives, which 55 percent of the participants reported to have done. Through interviewing, it was discovered that about 57 percent of the materials covered in WHE was grasped by the neighbours (12).
Regarding immunization of children, mothers' knowledge about immunization and the vaccine proved to have greater effect than the literacy of the mothers. Results of a study by Rahman et al. (5) show that even where widespread maternal illiteracy is prevalent, educating mothers about vaccine-preventable diseases and about the vaccines in general might be a very effective means of widening the immunization coverage. Bicego and Boerma (6) and Cleland and van Ginneken (3) also mention that immunization might not be related to maternal education (general). Mothers' knowledge about the vaccines and availability of services are sufficient to reach all children. Moreover, Rahman and other authors (13), in their study on "Impact of Health Education on the Feeding of Green Leafy Vegetables (GLV) at Home to Children of the Urban Poor Mothers of Bangladesh", found that health education on GLV had a great influence on the feeding practices even after controlling for family income and maternal literacy effects.
Although health education as such might be effective for the illiterate, health education cannot be a substitute for general education to ensure survival and health of the children. Rather, more lessons on topics necessary to know in order to maintain a healthy life should be included in the textbooks (such as the germ theory of disease, symptoms of diseases the presence of which should be consulted with a doctor, knowledge in first aid etc.). General education equips a person with literacy -- which gives her access to books and to the mass media, which keeps her up to date regarding new information on health affairs. However, it would certainly be very beneficial to arrange annual or bi-annual health education programs to review the major health issues (and the issue of pregnancy and child care which is difficult for primary school children to grasp).
Maternal Education as a Strategy
Now I wish to address the principal question of the paper-- whether maternal education should be used as a strategy for ensuring child survival or not. In light of the discussion above, it is evident that more research is needed to find out the specific mechanisms (which might vary from one society to another) through which maternal education works to prevent children's mortality. However, "widespread education appears indispensable for high survivorship" [(3) p.1366]. Lindenbaum (10) also asserts that female education can be used as a strategy to increase survival chances. Cleland and van Ginneken (3), and Lindenbaum (10) are of the opinion that medical interventions without mothers' education cannot be effective on their own.
At this point the question may be raised: How many years of schooling is required for education to have a substantial amount of effect on children's survival/health? According to a study by Mahalanabis et al. (8), in Bangladesh, schooling of seven years or more of the mothers reduced 55% risk of a child's being attacked by a severe disease resulting from diarrhea, but lesser number of schooling could not provide appreciable protection. Majumder and Islam's study in Bangladesh (7) shows that child survival index moves up from .764 to .811 with the increase of education from no schooling to 5 years of schooling (Primary level in Bangladesh). But the increase of index for the difference between primary level to secondary level or higher (at least ten years of schooling) is even greater, moving up from .811 to .882. Thus, the difference between child survival index rises from .764 to .882 with the difference of no schooling to ten or more years of schooling. Lindenbaum's (10) has mentioned a case of Khurshida, to show how a woman having seven years of schooling was able to ensure proper treatment for her sick child, after overcoming the different sorts of barriers, which came in her way. More studies should be carried out specifically to find out the least number of years of schooling necessary for a mother to become sufficiently conscious to maintain a style of life which is healthy and to use health services when necessary (which might differ from country to country). This, of course, depends on the amount of health education material included in the curriculum. It is my opinion that all the necessary aspects of health education covered in WHE (12) should be incorporated in the curriculum of the first five years of schooling, and taught in a way suitable for them to understand and practice, so that even if the dropout rate is high, children's understanding of health management would be more or less complete, which they can apply in their personal, family and community life.
Link and Phelan (14) urge social epidemiologist and medical sociologists to 'contextualize risk factors' through asking about the life circumstances that lead to the exposure to risk factors such as a poor diet. They rightly suggest that "efforts to reduce risk by changing behaviour may be hopelessly ineffective if there is no clear understanding of the process that leads to exposure" (p.29). For example, in a society, where socio-economic condition is declining, the effects of interventions for increasing people's health knowledge (either through general schooling, or through health education) for promoting health may not be as positive as might be perceived. Hussain and Kvale (4) studied the sustainability of "a health education intervention program called eNutritional Blindness Prevention Programme' (NBPP) in the northern part of Bangladesh". Through the program, efforts were made to raise "awareness and active participation" of people about the importance of eating food that were rich in carotene, protein items and taking vitamin A capsules for securing "a sustainable impact on food habits even after terminating active intervention in the community" [(4) P: 43]. The intervention period was three years (1986 to 1989) and as an effect of the intervention, prevalence of night blindness among children dropped from 50.7/1000 to 26.9/1000. However, three years after the intervention ended (in 1992), the prevalence rate increased again up to 40/1000, although the parents' knowledge regarding the definition of night blindness, its cause and prevention remained at a similar level. The consumption of dark-green leafy vegetables, milk, eggs, meat, fish and yellow fruits was reduced, which according to the study could be explained by the effect of the reduction of income over the previous three years (1989-1992). In this study, we see that although the parents had knowledge of the disease and its prevention procedures, their economic situation did not allow them to apply that knowledge. The results of this study support McKinlay's (15) argument that along with advocating edownstream' efforts like education, we should look for the eupstream' causes (in this case, the income of households) to determine the actual causes of illness.
McKinlay (15) introduces the concept of a 'need hierarchy', by which he refers to the fact that food, clothing and shelter are primary needs that take precedence over exercise, balanced diet, dental care etc. which are considered as secondary needs and less immediately important. This need hierarchy can be used to explain why the consumption of carotine-rich food declined even in the situation where the knowledge regarding the importance of eating fish, meat, eggs and dark green and yellow fruits and vegetables (to prevent night-blindness) existed among the people. Satisfying the pangs of hunger is the primary need for the people to meet -- with whatever food their income can buy. When this need is fulfilled, comes the question of eating certain kinds of food, the question of a balanced diet. When income is on the decline, the choices regarding food also reduce. Thus the information regarding the importance of eating certain kinds of food becomes useless before the bare reality of economic hardship. It is not only food, but also the basic living conditions of people, which are determined mostly by income. The illnesses (e.g. bronchitis, diarrhea, pneumonia etc.) that are caused by poor dwelling conditions and lack of supply of facilities (e.g. sanitary latrines, safe drinking water, electricity) cannot be averted by simply providing people with knowledge on the prevention and cure of diseases. We must delve into the root of mortality and morbidity situations -- the "upstream" causes of children's illness/mortality on order to ensure their survival and healthy life.
Thus, it is necessary to provide sufficient income, and alter the environment in such a way so that knowledge on proper maintenance of health can be applied. Moreover, health care services must be made available to the people, and proper services guaranteed. As Fauveau and other authors (16) suggest, "[i]n addition to preventive components such as tetanus and measles immunization, health and nutrition education, and family planning, curative services are needed to reduce mortality further" (p.103, abstract).
In view of all that has been said, I agree that maternal education, on its own is not sufficient to ensure survival of children. However, all other efforts in absence of maternal education cannot be fully effective either. Hence, we should look for ways in which maternal education can be the most effective to ensure children's health to determine the appropriate policy to be obtained. From the discussion of the studies above, the following can be suggested:
(1) At least seven years of schooling should be made compulsory for girls [on the basis of the study by Mahalanabis et al. (8), and by Lindenbaum (10), although further research should be carried out on the issue of the number of schooling required];
(2) All basic health issues (which might differ from society to society) should be covered in the textbooks and curricula of lower grades in school and be taught properly, so that even in cases of dropouts, the children will have sufficient health education to lead a healthy way of life, for themselves and their family and community.
(3) As it is difficult for school children aged 12 or below to understand the health issues related to pregnancy, child birth and child care, arrangements for health education (annual/bi-annual) concerned with these and other basic health issues must be made. Mother and child health care programs must function properly to be beneficial for the public. The health care centers must be situated at suitable distance (17), and convenient opening hours, friendly behaviour of the staff and supply of sufficient facilities and medicines must be ensured (18).
Thus, it can be said that in order to ensure children's survival, the governments of third world countries, world organizations, donor countries and Non-Government Organizations, must take initiatives to ensure literacy and sufficient health-knowledge for the mothers and also provide appropriate conditions and environment for them to apply that knowledge. This indeed is a great task. But this has to be ensured to ensure the survival of children.
I would like to acknowledge the suggestions and comments of Dr. Dorothy Pawluch, Department of Sociology, McMaster University, Canada.
1. Bolaria, B. Singh. 1994. Sociology, Medicine Health and Illness: An Overview. In B. Singh Bolaria and Harley D. Dickinson (eds.). Health, Illness and Health Care in Canada. Second Edition. Toronto: Hartcourt Brace and Company, Canada Ltd. Pp. 1-18.
2. Islam, Aminul M. and C.C. Neilson. 1993. Maternal and Child Health Care Services: Evaluating Mothers' Perceptions and Participation. Public Health 107:243-249.
3. Cleland, John G. and Jerome K. van Ginneken. 1988. Maternal Education and Child Survival in Developing Countries: The Search for Pathways of Influence. SSM 27(12):1357-68.
4. Hussain, A. and G. Kvale. 1996. Sustain ability of a Nutrition Education Programme to prevent Night-Blindness in Bangladesh. Tropical Medicine and international Health 1 (1):43-51.
5. Rahman, M., M.A. Islam, D. Mahalanabis. 1995 (Dec.). Mothers' Knowledge About Vaccine Preventable Diseases and Immunization Coverage in a Population with a High Rate of Illiteracy. Journal of Biosocial Sciences. 41 (6):376-8.
6. Bicego, George T. and J. Ties Boerma. 1993. Maternal Education and Child Survival: A Comparative Study of Survey Data from 17 Countries. SSM 36(9): 1207-1227.
7. Majumder, Abul Kashem and S. M. Shafiqul Islam. 1993. Socioeconomic and Environmental Determinants of Child Survival in Bangladesh. Journal of Biosocial Sciences. 25: 311-18.
8. Mahalanabis, Dilip, Abu S. G. Farouque, Asma Islam and Syed S. Hoque. 1996. Maternal Education and Family Income as Determinants of Severe Disease Following Acute Diarrhoea in Children: A Case Control Study. Journal of Biosocial Sciences. 28: 129-139.
9. Caldwell, J.C. 1981. Maternal Education as a Factor in Child Mortality. World Health Forum 2 (1):75-81.
10. Lindenbaum, Shirley. 1990. The Education of Women and the Mortality of Children in Bangladesh. In Alan C. Swedlund and George J. Armelagos (Eds.), Disease in Populations in Transition: Anthropological and Epidemiological Perspectives. New York: Bergin and Garvey. Pp. 353-370.
11. Guldan, Georgia S., Marian F. Zeitlin, Alex S. Beiser, Charles M. Super, Stanley N. Gershoff and Sabita Datta. 1993. Maternal Education and Child Feeding Practices in Rural Bangladesh. SSM 36 (7): 925-35.
12. Sloss, Laura J. and Ahmed Munier. 1991. Women's Health Education in Rural Bangladesh. SSM 32 (8): 959-961.
13. Rahman, M.M., M.A. Islam, D. Mahalanbis, F. Chowdhury and E. Biswas. 1994, May. Impact of Health Education on the Feeding of Green Leafy Vegetables at Home to Children of the Urban poor Mothers of Bangladesh. Public Health 103 (3): 211-8.
14. Link, Bruce G. and Jo Phelan. 1998.Social Conditions as Fundamental Causes of Disease. In William C. Cockerham, Michael Glasser and Linda S. Heuser (eds.). Readings in Medical Sociology. Upper Saddle River, New Jersey: Prentice hall. Pp. 23-26.
15. Mckinlay, John B. 1990. A Case for Refocusing Upstream: The Political Economy of Illness. In Peter Conrad and Rochelle Kern (eds.). The Sociology of Health and Illness. Third Edition. New York: St. Martin's press. Pp. 502-16.
16. Fauveau, Vincent, Bogdan Wojtyniak, Jyotsnamoy Chakraborty, Abdul Majid Sarder and Andre Briend. 1991. The Effect of Maternal and Child Health and Family Planning Services on Mortality: Is Prevention Enough? BMJ 301 (6743):103-7.
17. Paul, Bimal Kanti. 1991. Health Service Resources as Determinants of Infant Death in RuralBangladesh: An Empirical Study. SSM 32 (1): 43-49.
18. Ali, S.M., M.A. Paramanik, M.N. Khan and A, Samad. 1991. Assessment of Low Attendance atPrimary Health Centre. Bangladesh Medical Research Council Bulletin 17 (2):81-87.
Go back to EJAIB 11 (3)May 2001
Go back to EJAIB
The Eubios Ethics Institute is on the world wide web of Internet: