MATERIALS AND METHODS

To identify the influencing factors thought, to be the causes of early childhood mortality in Bangladesh, logistic regression analysis was used. It is similar to a linear regression model but is suited to models where dependent variable is dichotomous. The data for this study satisfy the conditions of unconditional logistic regression model (Matin, 1996).

Let Y_i represent a dichotomous variable that equals 1 if the mother experienced early childhood mortality and 0 if it was not, then the Pr (Y_i = 1), is the cumulative density function F evaluated at X_iβ, where, X_i is a vector of independent variables and β is a vector of unknown parameters. This kind of probability function has the following form:

The estimation of the logistic transformation of the probability of dead; Pr (Y_i = 1) can be represented as:

In this case, the dichotomous dependent variable is:

The set of independent variables are: (i) Mother’s age at birth, (ii) Sex of the child, (iii) Previous birth interval, (iv) Birth order, (v) Number of living children, (vi) Place of residence, (vii) Region, (viii) Mother’s educational level, (ix) Sources of drinking water, (x) Access to safe sanitation, (xi) Habit of reading newspapers or magazine and (xii) TT injection during pregnancy.

With the help of the employed methodology, the study intends to investigate the selected demographic, socio-economic and healthcare factors associated with early childhood mortality in Bangladesh. This study places analytical ground for better approach of integrating maternal and child health and family planning programs to reduce neonatal, infant and under-five mortality and statistical supports to observe effective policy scope in the way forward. Descriptive statistics, bivariate analysis and multivariate analysis employs to analyze the scope. A good number of information such as selected demographic, socio-economic and healthcare factors are associated in this study and which is drawn from the Bangladesh demographic and health survey (BDHS 2004 http://www.unescap.org/esid/psis/population/ popheadl ine/308/art4.asp). The BDHS sample covers the entire population residing in private dwelling units all over Bangladesh. The 2004 BDHS sample is a stratified, a multistage cluster sample consisting of 361 Primary Sampling Units (PSUs) of which 122 in the urban area and 239 in the rural area. After the target sample was allocated to each group according to urban and rural areas, the number of PSUs was calculated in terms of an average of 28 completed interviews of eligible women per PSU. A systematic sample of 10,811 households was selected and 10,523 were occupied of which 10,500 were successfully interviewed. In the sampling, 11,601 women were identified as eligible for the individual dialogue. Mitra and Associate (with the technical assistance from ORC Macro, NIPORT and Ministry of Health, Government of Bangladesh) conducted the survey which is utilized in this current study (NIPORT, 2003; NIPORT, 2005).

RESULTS AND DISCUSSION

The results in Table 1 provide insight into the nature of tradeoff between mortality rates and selected affecting factors. Here we present the mortality rates for the five years preceding the survey by selected characteristics and the mortality rates are counted here as the number of deaths per 1000 live births and examines differentials in early childhood mortality at various ages by demographic, socio-economic and health care characteristics of child and mother. The relationship between mother’s age at birth and childhood mortality (i.e., infant and under-five) rates exhibits a U-shaped pattern. Children of both the youngest and oldest mothers experience the highest mortality risks. But the mother’s age at birth is inversely related to neonatal mortality. Male children experience higher early childhood mortality than female children. The pattern of gender differentials is expected early childhood mortality (which reflects largely congenital conditions) tends to be higher for boys than girls. Short birth intervals are associated with increased risk of dying. We observe an association between short birth interval (less than 24 months) and increased mortality, even after controlling for other demographic and socio-economic variables. In Table 1, all childhood mortality rates show a sharp decline, as the birth interval gets larger. The neonatal, infant and under-five mortality rates are as twice as high for children born after an interval of less than 24 months, compared with children who are born after an interval of 48 months or more. Childhood mortality rates also tend to have a U-shaped relationship with birth order, with first births and very high order births having prominent mortality rates.

There is very little difference in mortality levels in urban and rural areas of infants. The neonatal and under-five mortality is still somewhat higher in rural areas than in urban areas. Mother’s level of education is inversely related to her child’s risk of dying. Higher levels of educational attainment are generally associated with lower mortality risks, since education exposes mothers to information about better nutrition, use of contraception to limit and space births and childhood illness and their treatment.

Table 1:	Mortality rate due to some selected characteristics
Mortality rates are counted here as the number of deaths per 1000 live births

The data shows that early childhood mortality declines sharply with increased level of mother’s education. The mortality risk of Children is associated with economic status of the household. The early childhood mortality rates are highest in limited access of hygiene sanitation, electricity usage and exposure of mass media. In addition, iron tablet and received any TT during pregnancy, ANC visits and PNC by qualified doctors also have positive role to reduce the risk of early childhood mortality. Chi square test (χ²) was adopted at a minimum level of significance for testing the association of various analyzed factors (such as selected demographic, socio-economic and health care) with the mother’s experience of early childhood mortality.

Table 2 represents the association between the early childhood mortality (neonatal, infant and under-five) and the selected demographic, socio-economic and health care variables. Among the selected demographic variables, preceding birth interval, birth order and number of living children are significantly associated with early childhood mortality.

Table 2:	Association between early childhood mortality and some selected variables
Significant level: p<0.001***, p<0.01**, p<0.05*

Mother’s age at birth is also associated only for neonatal and under-five mortality. Socio-economic variables such as, mother’s education, source of family drinking water and hygienic sanitation facilities are closely associated with early childhood mortality, though region and access to television is also associated in some context. Other socio-economic variables mentioned in Table 2 are not directly associated with early childhood mortality in Bangladesh. A significant relationship is found between early childhood mortality and health cares. Exposures to newspapers and magazines, tetanus injections and place of delivery are severely associated with child mortality. A mother who is more aware about health care is likely to less experience of early childhood mortality compared with their counterpart. Other variables like ANC and PNC visits and iron supplementation during pregnancy are not associated with childhood mortality but they need special attention.

The risk of early childhood mortality is significantly associated with mother’s age at birth, previous pregnancy interval, birth order and number of living children, mother’s educational level and habit of reading newspaper or magazine and TT injection during pregnancy. The likelihood of early childhood mortality is higher (Table 3) among mothers whose age at birth is 20+ compared with younger mothers. The odds ratios are 2-10 times higher compared with reference category with desired confidence intervals. The preceding birth interval is statistically significant showing that higher the birth interval is less likely to have risk of childhood mortality. The preceding birth interval of 24 months and above have 40 to 60% less likely to have risk of childhood morality compared with birth interval less than 24 months. Statistically significant results are also found in birth order numbers. Two to three birth orders are considered to be the ideal size with less early childhood mortality compared with single birth. This birth orders are 37 to 50% less likely to have risk of early childhood mortality compared with single birth. The number of living children also has significant affect on early childhood mortality. The odd ratios indicate that, more than four living children are highly significant and about 99% less likelihood of early childhood mortality compared with single living child with desired confidence intervals. Mother’s level of education has direct influence on early childhood mortality. The higher the education level, the less likelihood of risk associated with childhood mortality.

The odds ratios indicate that, the mother having completed primary level of education has 33 to 42% less risk of early childhood mortality compared with uneducated mother. In addition, the mother had higher education, 82 to 84% less risk of morality than their uneducated counterparts. Print media such as reading newspapers or magazines has influence on early childhood mortality in Bangladesh. The mothers who have the habit of reading newspapers or magazines at least once per week have 30 to 52% less risk of mortality, though the coefficients of neonatal and infant is relatively insignificant. Tetanus toxic injections during pregnancy have positive impact to reduce the early childhood mortality, though the odds ratio for neonatal is insignificant but TT injection has statistically significant for infant and under-five mortality.

Table 3:	Logistic regression analysis to determine the factors affecting under-five, infants and neonatal deaths
r: Reference category *p<0.05, **p<0.01, ***p<0.00; MAB: Mother age at birth, HEL: Highest educational level, PBI: Preceding birth interval, SDW: Source of drinking water, NLC: Number of living children, HRM: Habit of reading newspaper or magazine, TSTF: Type of safe toilet facility, PR: Place of residence, BO: Birth order number, TT: TT injection during pregnancy

The mothers who received any TT injections during pregnancy have 43 to 45% less risk of infant and under-five mortality compared with mother’s who never received any TT injection. On the other hand, the sex of child, place of residence, administrative regions, source of drinking water, safe toilet facility are not statistically significant, though they are associated with early childhood mortality as indicated by the chi-square test.

International studies on public policy confirm that the evidence on concrete policy discourse lacks in developing nations which generates heat in the discourse rather providing a decent policy of consensus (Al-Amin and Alam, 2011; Al-Amin et al., 2011; Kabir et al., 2011; Zarra-Nezhad and Hosainpour, 2011; Rezaie, 2011; Rouf, 2011; Javadein et al., 2011; Attitalla, 2011; Sohail and Munir, 2011; Aderibigbe et al., 2010; Ahortor, 2010; Sepehrdoust, 2009; Alam, 2009; Alam et al., 2009).

RECOMMENDATION AND CONCLUSION

This study identified the overall scenario of early childhood mortality and the factors that are affecting the problem in Bangladesh. The key factors are mother’s age at the time ‘birth giving’, ‘previous pregnancy interval’, ‘birth order’ and level of mothers’ education. Therefore, to offer a solution to the problem, ‘maternal health care services’ should be given a high level of preference. Statistical techniques identified some important determinants of early childhood mortality. The findings also suggest in favor of providing a fair access and available heath services to all children. Widely justified integrated maternal and family planning programs are also important to reduce neonatal, infant and under-five mortality. Being an underdeveloped country, Bangladesh is in urgent need to come out with a way of that ensures sufficient information to make accurate localized risks for health-care issues to the national policy orientation.

Setting an ‘agenda table’ involving a number of important stakeholders, legislators and implementers with an use of the findings of this study and along with past and future studies, a policy ensuring a room for further revisions need to put in place with an important and urgent commitment of the state. The policy guideline should provide an attention on pre-pregnancy and postnatal health care for all clusters of the people of the society for reducing the shortfalls. Evident and experience suggest that improving children mortality through community and home-based strategies have also the potential to reduce children mortality. Therefore, nation needs to walk a further step on community and home-based strategies to response the commitments made by the nation towards MGD4.

ACKNOWLEDGMENT

This study is the outcome of secondary data sources with no financial support and there is no conflict of interest. We have our cordial acknowledgment to the MEASURE DHS, Macro International Inc., 11785 Beltsville Drive, Suite 300, Calverton and USA for giving us access to their database.