Infant mortality and family welfare: policy implications for Indonesia. (Public Health Policy and Practice).

Study objective: To examine the effect of family welfare index (FWI) and maternal education on the probability of infant death.

Design: A population based multistage stratified clustered survey.

Setting: Women of reproductive age in Indonesia between 1983--1997.

Data sources: The 1997 Indonesian Demographic and Health Survey.

Main results: Infant mortality was associated with FWI and maternal education. Relative to families of high FWI, the risk of infant death was almost twice among families of low FWI (aOR=1.7, 95% Cl = 0.9 to 3.3), and three times for families of medium FWI (aOR=3.3, 95% Cl = 1.7 to 6.5). Also, the risk of infant death was threefold higher (aOR = 3.4, 95% Cl = 1.6 to 7.1) among mothers who had fewer than seven years of formal education compared with mothers with more than seven years of education. Fertility related indicators such as young maternal age, absence from contraception, birth intervals, and prenatal care, seem to exert significant effect on the increased probability of infant death.

Conclusions: The increased probability of infant mortality attributable to family income inequality and low maternal education seems to work through pathways of material deprivation and chronic psychological stress that affect a person's health damaging behaviours. The policies that are likely to significantly reduce the family's socioeconomic inequality in infant mortality are implicated.

Between 1987 and 1990 about nine million infants died annually worldwide, yielding a global infant mortality rate (IMR) of 67 per 1000 live births.(1) Furthermore, evidence worldwide showed that those from lower socioeconomic status have higher morbidity and mortality rates, (2) and action from every country to increase public health spending aimed at reducing socioeconomic inequality in infant mortality is called. (3)

In Indonesia, IMR has been declining; from 142 in 1967--1971 to 46 per 1000 in 1992--1997 period. (4) The rapid decline in IMR in Indonesia disguises the differential in infant mortality among geographical areas and socioeconomic groups. The urban-rural inequality in IMR has been widening; namely 42% higher in rural compared with urban regions. (5,6) Gwatkin indicated that the mortality differentials in Indonesia were associated with socioeconomic status, measured by Wealth Quintiles and a Poor/Rich Ratio. (7) Other studies have also shown that infants from low socioeconomic families are at greater risk for illness and death than high socioeconomic status families. (7-15)

There are numerous studies that show that IMR is closely associated with various potential risk factors, namely ethnicity, education of the mother, access to and use of health services, and residence--urban compared with rural (16-17) antenatal and postnatal care,(18) low birth weight, (19-21) the absence of breast feeding, (22) prematurity, (23) birth order, (24) young maternal age and frequent birth interval, (25) overcrowding and population density, (29) as well as the use of medical services. (30)

The relation between socioeconomic status and health status including IMR, have been extensively reported over the years and the relation has been replicated in both developed and developing countries using almost every measure of adverse health outcome. (2,27,28) The World Bank has highlighted using data from 115 countries that the level of income per capita and education significantly predict the countries health performance: that between 1960 and 1990, the health conditions of countries improved when the level of education increased along with increases in per capita income. (29)

In 1997, Indonesia undertook the Demographic and Health Survey (IDHS), assisted by the Macro International-USA (MI-USA). (30) This is the first study to model the association between infant mortality, family welfare status (FWI), and maternal education adjusting for potential risk factors and geographical variation.

METHODS

Sources of data

The data were obtained from the MI-USA. The IDHS follows a three stage stratified probability sampling design, where the sample was stratified into 27 provinces. A sample of 34 255 households (response rate 99%) were randomly selected from 1413 Primary Sampling Units (PSUs). The average cluster size was 25 households per PSU. The demographic and health data were obtained by interview from 28 810 reproductive women aged 15 to 49 years (response rate 98%). To produce adjusted and non-biased estimates at the appropriate levels of aggregation (national, regional, provincial and urban-rural), weights were applied to the data. (31)

Study variables

A binary outcome variable was selected, namely whether or not each of the live born infant(s) from the interviewed women was alive or dead in the 12 months after birth.

Of interest were the variables related to socioeconomic status, measured by the FWI and length of maternal education. The FWI is a unique nationally adopted index of family welfare status," used to monitor changes in the level of poverty and welfare at the household level. (33) It consist of five levels of family welfare status, namely pre-prosperous, low prosperous, medium prosperous, high prosperous, and very high prosperous families, (32, 34) In this study, FWI was categorised into three levels namely, high (medium to very high prosperous), medium (low prosperous), and low (pre-prosperous). These three levels of FWT were interpreted as rich, near poor, and poor families. (35) Length of maternal education was dichotomised into two levels namely, less than seven or seven or more years of formal education.

The following risk factors were investigated, namely: current contraceptive method, birth intervals, maternal age at first birth, marital duration, infants' size perceived by the mothers, infants' birth …