Abstract
SummaryBackgroundThe educational attainment of parents, particularly mothers, has been associated with lower levels of child mortality, yet there is no consensus on the magnitude of this relationship globally. We aimed to estimate the total reductions in under-5 mortality that are associated with increased maternal and paternal education, during distinct age intervals.MethodsThis study is a comprehensive global systematic review and meta-analysis of all existing studies of the effects of parental education on neonatal, infant, and under-5 child mortality, combined with primary analyses of Demographic and Health Survey (DHS) data. The literature search of seven databases (CINAHL, Embase, MEDLINE, PsycINFO, PubMed, Scopus, and Web of Science) was done between Jan 23 and Feb 8, 2019, and updated on Jan 7, 2021, with no language or publication date restrictions. Teams of independent reviewers assessed each record for its inclusion of individual-level data on parental education and child mortality and excluded articles on the basis of study design and availability of relevant statistics. Full-text screening was done in 15 languages. Data extracted from these studies were combined with primary microdata from the DHS for meta-analyses relating maternal or paternal education with mortality at six age intervals: 0–27 days, 1–11 months, 1–4 years, 0–4 years, 0–11 months, and 1 month to 4 years. Novel mixed-effects meta-regression models were implemented to address heterogeneity in referent and exposure measures among the studies and to adjust for study-level covariates (wealth or income, partner's years of schooling, and sex of the child). This study was registered with PROSPERO (CRD42020141731).FindingsThe systematic review returned 5339 unique records, yielding 186 included studies after exclusions. DHS data were compiled from 114 unique surveys, capturing 3 112 474 livebirths. Data extracted from the systematic review were synthesized together with primary DHS data, for meta-analysis on a total of 300 studies from 92 countries. Both increased maternal and paternal education showed a dose–response relationship linked to reduced under-5 mortality, with maternal education emerging as a stronger predictor. We observed a reduction in under-5 mortality of 31·0% (95% CI 29·0–32·6) for children born to mothers with 12 years of education (ie, completed secondary education) and 17·3% (15·0–18·8) for children born to fathers with 12 years of education, compared with those born to a parent with no education. We also showed that a single additional year of schooling was, on average, associated with a reduction in under-5 mortality of 3·04% (2·82–3·23) for maternal education and 1·57% (1·35–1·72) for paternal education. The association between higher parental education and lower child mortality was significant for both parents at all ages studied and was largest after the first month of life. The meta-analysis framework incorporated uncertainty associated with each individual effect size into the model fitting process, in an effort to decrease the risk of bias introduced by study design and quality.InterpretationTo our knowledge, this study is the first effort to systematically quantify the transgenerational importance of education for child survival at the global level. The results showed that lower maternal and paternal education are both risk factors for child mortality, even after controlling for other markers of family socioeconomic status. This study provides robust evidence for universal quality education as a mechanism to achieve the Sustainable Development Goal target 3.2 of reducing neonatal and child mortality.FundingResearch Council of Norway, Bill & Melinda Gates Foundation, and Rockefeller Foundation-Boston University Commission on Social Determinants, Data, and Decision Making (3-D Commission).
Highlights
Education and child survival have both been at the heart of the international development agendas for decades,[1,2,3] yet large inequalities in education attainment persist within and between countries,[4] as do large inequalities in child mortality rates.[5,6] Despite decades of reports documenting education-related disparities in child sur vival, to our knowledge, no study to date has attempted to systematically quantify the effect of parental education on under-5 mortality on a global scale
Previous research has sought to quantify the effect of maternal education on child mortality, but reviewed only a portion of evidence available, namely from select Demographic and Health Survey (DHS) waves in low-income and middle-income countries
Most studies on this topic have looked only at maternal education, where the weight of evidence has indicated a link to child survival, and focused heavily on the neonatal period rather than later child mortality
Summary
Education and child survival have both been at the heart of the international development agendas for decades,[1,2,3] yet large inequalities in education attainment persist within and between countries,[4] as do large inequalities in child mortality rates.[5,6] Despite decades of reports documenting education-related disparities in child sur vival, to our knowledge, no study to date has attempted to systematically quantify the effect of parental education on under-5 mortality on a global scale. From 2011, found that increased maternal education improved the likelihood of infant survival independent of household economic resources, with use of cluster-level, rather than individual-level, data. Most studies on this topic have looked only at maternal education, where the weight of evidence has indicated a link to child survival, and focused heavily on the neonatal period rather than later child mortality. Each of these studies has contributed important knowledge to the field, crucial questions about the scope and magnitude of how both parents’ education might influence child mortality have remained unanswered
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