Health is no longer defined by the narrow 'germ theory' of disease; the holistic approach has recognized that health is multifactorial1. In addition, the link between education and health is now well established, and growth in literacy rates, particularly among women, has been shown to have a positive impact on health2. The 2006 Nepal Demographic Health Survey showed large discrepancies in health service usage and health outcomes, according to the literacy status of respondents, particularly women3.
According to the Nepalese data, there is a large difference among women in the rate of births assisted by a skilled birth attendant (SBA), one of the most important indicators for maternal health3. Births to women with school leaving certificate (SLC) and above education were almost nine times (71%) as likely to receive assistance from an SBA as were births to mothers with no education (8%). Some other differences in child health indicators, according to the mother's education level, are shown (Table 1) and include the following. Immunization coverage of children born to a mother with no education was 74%, compared with 99% of the children of mothers with SLC and above - a gap of almost 25%. A large gap was also observed in maternal and child nutritional status. The proportion of women with BMI <18.5 (an important indicator of poor nutritional status) was almost double in women with no education (29%), compared with those whose education was SLC and above (13%). The stunting of children among mothers with no education (58%) was almost four times higher than that of children whose mothers had SLC and above (16%). The fertility rate was more than double in women with no education (3.9%), compared with women with SLC and above (1.8%). Mortality under 5 years of age was 93 per 1000 live births among children born to mothers with no education, more than seven times higher than that of children born to a mother with SLC and above (13 per 1000 live births). Similar differences were found in infant and neonatal mortality.
Table 1: Maternal and child health differentials according to mother's education
In addition, rural Nepalese women have been shown to be disadvantaged in health, education and economic status, compared with their urban counterparts. There are large differences between urban and rural women in utilization of health care services. For example, fewer rural women have: four or more antenatal care visits (rural 26% vs urban 52%); delivery assisted by SBA (rural 14% vs urban 51%) and contraceptive use (rural 42% vs urban 54%). Similarly, only 51% of rural women are literate, compared with 76% of their urban counterparts3,4.
To adress these inequities, interventions must be made beyond the health sector. Numerous studies over the past decade have found an almost universal positive association between a mother's schooling and her child's survival5,6. Kerala State in India is a striking example of this, with high levels of health improvement achieved when efforts in the health field were simultaneously reinforced by developments in other sectors, especially in female literacy1. Child health status has been demonstrably improved with an increase in maternal education in all income groups, except in the very poorest groups7. In fact, education promotes not only literacy, but also a wider understanding of the socio-cultural, economic and political factors that shape human development. Education promotes health and wellbeing by enabling individuals to critically analyze their own situation. Thus, an investment in the education of rural women in Nepal would greatly assist the achievement of improved maternal and child health outcomes.
Gagan Gurung, MPH
Save the Children
1. Park K. Park's textbook of preventive and social medicine, 18th edn. Jabalpur, India: Banarsidas Bhanot Publisher, 2005.
2. Indira Gandhi National Open University. Health in rural India. New Delhi: Young, 2001.
3. Ministry of Health and Population. Nepal Demographic and Health Survey. Kathmandu: New ERA, 2006.
4. Ministry of Health. Family Health Survey. Kathmandu: New ERA, 1996.
5. Govindasamy P, Ramesh BM. Maternal education and the utilization of maternal and child health services in India. Mumbai: International Institute for Population Sciences, 1997.
6. Desai S, Alva S. Maternal education and child health: is there a strong causal relationship. Demography 1998; 35: 71-81.
7. Otta BM. The impact of maternal education on the health of the child. Journal of Family Welfare 1992; 38: 19-24.