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BACKGROUND: Socioeconomic status at national, sub-national, household, and individual levels explains a significant portion of variation in infant mortality. Women’s education is among the major determinants of infant mortality. The mechanism through which a woman’s own educational status, over her husband’s as well as household characteristics, influences infant mortality has not been well studied in developing countries. The objective of this study was to explore the role of woman’s empowerment and household wealth in the association between a woman’s educational status and infant mortality.
A secondary serial cross-sectional analysis was conducted utilizing data from three rounds of EDHS administered in 2000, 2005, and 2011. EDHS is a regular survey conducted every five years by the Central Statistical Authority of Ethiopia. In each survey, data was collected from nationally representative samples of females aged 15 to 49 years selected through multistage sampling. The number of interviewed females was 15,367 in the 2000 EDHS, 14,070 in the 2005 EDHS, and 16,515 in the 2011 EDHS, making a total of 45,952 respondents (5, 24, 25). Among all female respondents, 16,267(35.4%) met the eligibility criteria of being married and having at least one birth during the five years period prior to date of interview. Data on five year birth history of eligible women was pooled from the survey datasets allowing the analysis to span the period 1996 to 2011. Measures: The primary outcome was the mother having experienced infant death-defined as having at least one infant death among births in five years prior to the survey. If any of the newborns within the five years period died before 12 completed months of life, the mother was considered to have had infant death. The primary exposure was maternal education. Educational status was assessed based on the highest category of school completed (no education, primary, secondary or higher level education) on an ordinal scale. Wealth index, categorized in quintiles to reflect cumulative living standard of a household in terms of relative wealth, was measured based on “easy-to-collect data on a household’s ownership of selected assets such as televisions and bicycles; materials used for housing construction, and types of water access and sanitation facilities”. Women were categorized into five categories: poorest, poorer, middle, richer, and richest in terms of where their household falls in the distribution of the original sample (26). Woman’s empowerment, closely related to the concept of female autonomy introduced in the work of Dyson and Moore during the early 1980s (27), has been widely defined and measured in the social science literature during the past three decades (28–30). Despite contrasts made by some authors that view empowerment as a process of achieving autonomy, the concepts fundamentally share measures related to the freedom of a woman in making decisions affecting her own life (30). In our study, woman’s empowerment was defined as the level of involvement (participation) of the woman in making decisions at the household level. We constructed a composite numeric variable based on three questions of involvement: involvement in decisions about own healthcare, major household purchases, and decisions about visiting relatives. The three items were found to be highly correlated and had an internal consistency Cronbach’s alpha value of 0.844. A woman was considered to be participating in decision making when household decisions are made jointly by husband and wife, primarily by wife or jointly by woman and someone else. Level of empowerment was then quantified as the number of decisions a woman participated with possible values ranging from 0 to 3. Sampling Weights: DHS in most countries including Ethiopia oversamples smaller regions and undersamples larger regions with the purpose of achieving representative sample size at subnational level while keeping total sample size manageable. As a result, it is recommended to weight cases during descriptive analysis of DHS data at national level (26). In this study, two additional non-self-weighting steps were involved: 1) we took only a subset of the original dataset based on the eligibility criteria of being married and having at least one birth in five years before the survey, and 2) we merged data from three rounds of surveys representing different population sizes because of population growth. Therefore, we adjusted the original woman’s individual sample weight in a way that allowed maintaining the total number of cases equal between weighted and unweighted analyses while at the same time accounting for differences in the number of women represented by each sample in the final dataset. Weighting was applied only for descriptive analysis. Data Analysis: Univariate, bivariate and multivariate analyses were conducted with SPSS version 22.0 for Windows (31). The association between experiencing infant death and a woman’s educational status, level of empowerment, household wealth and potential confounders including age in years, type of residential area, and husband’s educational status was examined using cross-tabulations and Chi-Square tests for independence. Multivariate logistic regression was used to control the effect of potential confounders and in testing mediation and moderation. We hypothesized that: The association between woman’s education and experience of infant death was assessed by regressing experience of infant death on level of education. We then included potential confounders. Mediation analyses followed recommended steps (32, 33), whereby the relation between household-level woman empowerment and household SES is examined and if significant, included in the model, separately, to see if they attenuate the association between woman’s education and experience of infant death. This mediated effect was also examined using the Sobel Test (34, 35). We assumed no confounding between the mediator and outcome as well as no interaction between the exposure and mediator. All potential confounding factors between the mediator and outcome were included in final models. Finally, stratified analysis was conducted to examine whether the impact of woman’s education and empowerment on experience of infant death varied by wealth categories.
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