Social context, social position and child survival : Social determinants of child health inequities in Nigeria

Abstract: Under-five mortality rate is a key indicator of the level of child health and overall well-being of a given population and is an indicator of the United Nations Millennium Development Goals 4. Of the estimated more than 10 million children that die worldwide each year, 41% of these deaths occur in sub-Saharan Africa. With over one million children dying yearly from preventable diseases in Nigeria, the country may not meet the other Millennium Development Goals by 2015. Child survival in Nigeria is threatened by poverty, nutritional deficiencies and illnesses, such as malaria, diarrhoeal diseases, acute respiratory infections, high maternal morbidity, mortality and vaccine preventable diseases. These are closely associated with measures of social position. The overall aim of this thesis was to contribute to an understanding of the underlying mechanisms of child health inequities in under-five mortality in Nigeria in relation to socialcontext, social stratification and social position. Specific objectives were to assess the role of mothers religious affiliation, ethnicity, rural-urban migration and residence in disadvantaged urban neighbourhoods on under-five mortality in Nigeria. Data from the 2003 Nigeria Demographic and Health Survey was used in these studies. This is a nationally-representative probability sample of 7864 households collected using a stratified twostage cluster sampling procedure, from which data was collected by face-to-face interviews from 3725 women aged 15 to 49 years. These women contributed a total of 6029 live born children born to the survey. Information collected included birth histories, in-depth demographic and socio-economic information on illnesses, medical care, immunizations, and anthropometric details of children. The relationships between under-five mortality and mothers religious affiliation was analysed in paper 1 using Cox regression. In papers II IV, we used multilevel logistic regression analysis to assess the relationship between ethnicity, rural-urban migration and residence in disadvantaged urban neighbourhoods and under-five mortality. Multivariate analyses showed that religious mortality differences were closely associated with the differential use of maternal and child health services among mothers of Traditional indigenous religion, which are in turn associated with poverty and low socio-economic position. Ethnic mortality differences were dependent in part on differences in individual-level socioeconomic characteristics, and less directly related with inter-ethnic variation in health behaviour of the mothers. Applying three migration perspectives, mortality differences among migrant groups were associated with disruption of the migrant s social and economic well-being, their demographic and socio-economic selectivity, disparities in adaptation (utilization of maternal health services) due to underlying socio-economic differences between and within migrant and nonmigrant populations, as well as the influence of community contexts. Residence in disadvantaged urban areas was associated with increased risks of under-five deaths. The risks increased with increasing level of disadvantage, and were explained both as a direct effect of living in a disadvantaged neighbourhood, and indirectly as a result of the socioeconomic characteristics of people living in these disadvantaged neighbourhoods. Together, the observed mortality differences among children of mothers assessed by the different measures of social position in this thesis are a reflection of the health inequities confronting children of mothers in low social positions.