Social determinants of inequalities in child mortality, child under-nutrition and maternal health services in Bangladesh

Abstract

Introduction: In recent years the idea of inequality has been revitalised in the global discourse of development. Despite experiencing significant achievements in addressing the Millennium Development Goal, the fight against inequality remained an unfinished agenda. Disparities in child and maternal health & nutrition exist in almost every low and middle-income country. The global community is increasingly recognising the fact that while a country may be on track to achieve specific targets, the situation concerning some subgroups of the population may remain the same or even worsen over time. To address inequalities within a country, it is thus critical to understand the determinants of inequalities. Social determinants of health, which denote the economic and social conditions and their distribution among the population, have significant influences on individual health conditions. To reduce inequalities in maternal and child health and undernutrition in Bangladesh, it is thus imperative we take proper action on the social determinants of health. But the foremost task is to understand the specific role of social determinants of inequalities in the health and nutrition of the mother and the child. Objectives: Overall the research aims to examine the role of social determinants of health in explaining the inequalities in child health, child under-nutrition and maternal health services in Bangladesh. The specific objectives are to examine the role of social determinants in explaining the inequalities in childhood mortality, childhood malnutrition and maternal health services in Bangladesh. The research also aims to assess the feasibility of monitoring social determinants of health in Bangladesh and testing innovative approached to address inequality in child undernutrition. Methods: Data for Chapter 3, 4, 5 and 6, data were derived from Bangladesh Demographic and Health Surveys, while data for Chapter 7 and 8 were derived from Bangladesh Maternal Mortality and Health Care Survey 2010. Multilevel logistic regression analysis was used in Chapters 3 and 8. The study used decomposition of concentration index method to assess the contribution of social-determinants to the inequality in Chapters 4, 5, 6 and 7. The study also used horizontal inequity index (HII) to measure the horizontal inequity. For measuring the feasibility of monitoring social determinants of health and testing of a mobile-based integrated package to improve maternal and child nutrition among low-income families, the study undertook a mixed method approach. Results: Chapter 3 reported the current situation of universal health coverage in Bangladesh based on priority indicators from a suggested UHC framework. For several priority public-health interventions, the country has reached relatively high levels of coverage with greater equity. For example, Bangladesh has achieved high vaccine coverage while reducing disparities significantly between different wealth quintiles. The primary treatment coverage for diarrhoea and acute respiratory infections (ARI) has also improved. In 2011 81% of under-five children with diarrhoea were treated with ORS. Among children with ARI, 35% were taken to a health facility or a health care provider, and 71% received an antibiotic. Bangladesh’s progress with interventions to combat malnutrition has been mixed. According to the latest DHS, 90% of children are breastfed until the age two years and 64% of children less than age 6 months are exclusively breastfed. However, a mere 21% of children age 6-23 months are appropriately fed based on recommended infant and young child feeding practices. The country has done less well with specific interventions that require relatively higher clinical care, For example, the rate of delivery assisted by skilled birth attendants is only 32%. Chapter 4 examined the mortality differentials in children of different age groups by key social determinants of health (SDH). Our study reported that the mother’s age, parental education, the mother’s autonomy to make decisions about matters linked to the health of her child, the household socio-economic conditions, the geographical region of residence, and the condition of the roads were significantly associated with higher risks of neonatal, infant, and under-five mortality in Bangladesh. Chapter 5 measured the extent of socioeconomic‐related inequalities in childhood stunting and identified the key social determinants that potentially explain these inequalities in Bangladesh. The study reported significant inequality in stunting prevalence in Bangladesh. The negative concentration index of stunting indicated that stunting was more concentrated among the poor than among the well‐off. Our results suggest that inequalities in stunting increased between 2004 and 2014. Household economic status, maternal and paternal education, the health‐seeking behaviour of the mothers, sanitation, fertility, and maternal stature were the significant contributors to the disparity in stunting prevalence in Bangladesh. Chapters 6, 7 and 8 examined the inequities in access to maternal health services (facility delivery and caesarean section) and identified the key social determinants that can potentially explain such inequities. Chapter 6 reported that the use of caesarean sections for delivery is mainly driven by the social determinants of health. Household economic status; women’s education, and neighbourhood prevalence of caesarean sections contributed the most to this socioeconomic inequality. Chapter 7 reported that facility delivery in Bangladesh Nepal and Pakistan is driven mostly by the social determinants of health rather than individual health risks. Household socioeconomic condition, parental education, place of residence and parity emerged as the most critical factors. Chapter 8 reported that there is a substantial amount of variation at the community level in the use of facility delivery services. Among the community level factors place of residence, low concentration of poverty in the community, the high concentration of use of antenatal care services in the community, the high concentration of media exposure and high concentration of educated women in the community were found to be significantly associated with facility delivery. Among other individual and household level factors maternal age, educational status of the mother, religion, parity, delivery complications, individual exposure to media, individual access to antenatal care and household socioeconomic status showed strong association with facility delivery. Chapter 9 reported the relevance of a set of indicators of social determinants of health in tracking progress in universal health coverage and population health in Bangladesh and three other countries. For most countries, monitoring is possible. However, a qualitative assessment showed that technical feasibility, reliability, and validity varied across indicators and countries. Producing understandable and useful information proved challenging, and particularly so in translating indicator definitions and data into meaningful lay and managerial narratives, and efficiently communicating links to health and ways in which the information could improve decision-making. Chapter 10 tested an intervention package of voice messaging, direct counselling through mobile phones and an unconditional cash transfer for changing perceptions on nutrition during pregnancy and first year of the child’s life. The study aims to assess the feasibility and acceptability of an integrated package of nutrition counselling, and unconditional cash transfers all on a mobile platform for changing perceptions on nutrition during pregnancy and the first year of the child’s life. The study was a mixed method pilot study with 340 women. The women were either pregnant or lactating. The intervention consisted of an unconditional cash transfer combined with nutrition counselling both delivered on a mobile platform. The participants received BDT 787 per month and a mobile phone. The nutrition messages were delivered by a voice messaging service. Additional nutrition counselling were provided by a nutrition counsellor from a call centre. The poor rural women were interested both in voice messages and direct counselling. Most women reported that they had no problem in operating the mobile phones and listen to the voice messages. There were also able to interact freely with the counsellor. Charging of the mobile handsets posed some challenges. No significant barriers were identified with the use of mobile banking for cash transfers. Regarding the use of cash, our study reported that one of the highest priorities for low-income families was purchasing food. Chapter 11 describes the study protocol of a cluster randomised controlled trial that aims to assess the impact of a cash and nutrition counselling based interventions, randomised among villages with an objective of improving the nutritional status of children less than two years of age to reduce stunting. The proposed trial will provide high-level evidence of the efficacy and cost-effectiveness of a behaviour change communication intervention combined with unconditional cash transfers in reducing child undernutrition in rural Bangladesh. This trial of an innovative approach to enhancing the impact of cash transfers on child nutrition will be a leading study to guide future policies about how to reduce inequalities in child undernutrition in low income and food insecure populations. Conclusions: Health equity is considered as a critical component of progressive achievement of universal health coverage as part of the Sustainable Development Goals (SDG 3). The results of the research presented in this thesis demonstrate the importance of reducing the inequalities in social determinants of health to reduce socioeconomic inequalities in health and nutrition outcomes. There is no simple solution to tackle inequalities in the social determinants of health. The mechanisms producing social hierarchy are different in different settings so there is no strategy that will be effective for every socio-political context. It is now well established that contextual factors that produce the social hierarchy or social stratification are within people’s control. There are evidence-based actions that can address the determinants of health inequities adequately, and such steps are politically achievable. Policymakers should not limit their focus towards intermediary determinants but also try to tackle the underlying structural determinants of health inequalities. A coordinated multi-sectoral approach will be needed to combat the inequalities in the social determinant of health.