Geographic Differentials in Mortality of Children in Mozambique: Their Implications for Achievement of Millennium Development Goal 4.

2012·0.38 MB·English

by  Macassa, Gloria

J HEALTH POPUL NUTR 2012 Sep;30(3):331-345 ©INTERNATIONAL CENTRE FOR DIARRHOEAL
ISSN 1606-0997 | $ 5.00+0.20 DISEASE RESEARCH, BANGLADESH
Geographic Differentials in Mortality of Children in
Mozambique: Their Implications for Achievement
of Millennium Development Goal 4
Gloria Macassa1,2,3, Gebrenegus Ghilagaber4, Harry Charsmar5,
Anders Walander2, Örjan Sundin6, Joaquim Soares3
1Department of Occupational and Public Health Sciences, University of Gävle, 80176 Gävle, Sweden; 2Department of Public Health
Sciences, Division of Social Medicine, Karolinska Institute, SE-17176, Sweden; 3Division of Public Health Sciences, Mid-Sweden
University, 85170, Sundsvall, Sweden; 4Department of Statistics, Stockholm University, SE-106 91, Sweden; 5Department of Sociology,
Stockholm University, SE-106 91, Sweden; 6Department of Psychology, Mid-Sweden University, 83125 Östersund, Sweden
ABSTRACT
In the light of Mozambique’s progress towards the achievement of Millennium Development Goal 4 of
reducing mortality of children aged less than five years (under-five mortality) by two-thirds within 2015,
this study investigated the relationship between the province of mother’s residence and under-five mortal-
ity in Mozambique, using data from the 2003 Mozambican Demographic and Health Survey. The analyses
included 10,326 children born within 10 years before the survey. Results of univariate and multivariate
analyses showed a significant association between under-five mortality and province (region) of mother’s
residence. Children of mothers living in the North provinces (Niassa, Cabo Delgado, and Nampula) and the
Central provinces (Zambezia, Sofala, Manica, and Tete) had higher risks of mortality than children whose
mothers lived in the South provinces, especially Maputo province and Maputo city. However, controlling
for the demographic, socioeconomic and environmental variables, the significance found between the
place of mother’s residence and under-five mortality reduced slightly. This suggests that other variables
(income distribution and trade, density of population, distribution of the basic infrastructure, including
healthcare services, climatic and ecologic factors), which were not included in the study, may have con-
founding effects. This study supports the thought that interventions aimed at reducing under-five mortal-
ity should be tailored to take into account the subnational/regional variation in economic development.
However, research is warranted to further investigate the potential determinants behind the observed dif-
ferences in under-five mortality.
Key words: Child mortality; Economic development; Infant mortality; Millennium Development Goals;
Mozambique
INTRODUCTION ity of children aged less than five years (under-five
mortality) by two-thirds within 2015. However,
In September 2000, Mozambique joined other
as stated by the UN report on the progress of the
countries in signing the declaration which launched
MDGs in 2010, child deaths are falling but not
the United Nations Millennium Development quickly enough to reach the target (1). The report
Goals (MDGs), with 1990 scenario as baseline. Of found that, overall, sub-Saharan Africa still experi-
the eight MDGs, Goal 4 aims at reducing mortal- ences high levels of under-five mortality compared
to other regions of the world, although a reduc-
Correspondence and reprint requests:
tion has occurred from 184 per 1,000 livebirths in
Dr. Gloria Macassa
1990 to 144 per 1,000 livebirths in 2008 (1). Fur-
Department of Occupational and Public Health Sciences
ther, the report found that some countries in the
University of Gävle
sub-Saharan Africa region have achieved absolute
80176, Gävle
reductions in under-five mortality against the odds
Sweden
of poverty. These countries include Mozambique,
Email: [email protected] OR
Ethiopia, and Malawi (1).
[email protected]
Fax: [phone] Although the baseline figures for mortality in 1990
Geographic differentials in mortality of under-five children in Mozambique Macassa G et al.
are not available for Mozambique, the most recent Geographically, the country exhibits substantial
country report on the progress towards the achieve- differences in welfare and economic development,
ments of MDGs shows that under-five mortality has with a high concentration of economic activities,
declined from 219 per 1,000 livebirths in 1997 to infrastructure, and basic services (including health-
178 per 1,000 in 2003 (1,2). In addition, data from care facilities) in and around the capital Maputo
the most recent Multiple Indicator Cluster Survey city, situated in the very south of the country (4)
(MICS) showed that a further reduction has taken (Table 2). This has resulted in differences in the
place, and in 2008, under-five mortality reached development of regional welfare, which are impor-
154 per 1,000 livebirths (3). However, despite this tant issues in Mozambican society and politics.
positive development in under-five mortality rates
To understand the role of province (region) of resi-
at the national level, there is a growing concern re-
dence in the differentials of under-five mortality in
garding the persisting geographical differences in
Mozambique, this study relies on the framework of
under-five mortality (1) (Table 1).
the proximate determinants by Mosley and Chen
(5). The model of the proximate determinants was
The 2010 country report on the MDGs for Mo-
developed to study the factors affecting child mor-
zambique noted that there were great geographical
tality and is based on the idea that all social and
differences in under-five mortality. A child in the
economic determinants of child mortality operate
North province of Cabo Delgado was three times
through a set of biological or proximate determi-
more likely to die before the age of five years than
nants to affect a child’s probability of survival (5).
a child born in Maputo city (1). According to the
The model combined social, economic, medical
report, infant mortality was lower in the Southern
and biological explanations of child mortality.
region compared to the Central and Northern re-
Mosley and Chen (5) grouped the proximate de-
gions of the country, with the mortality rate of 147
terminants into five categories: (i) maternal factors
per 1,000 livebirths in Zambezia and 131 per 1,000
(age, parity, and birth interval); (ii) environmental
livebirths in Cabo Delgado (1). The rates of child
contamination (air, food/water/fingers, skin/soil/
mortality were 180 per 1,000 livebirths and 205
inanimate objects, and insect vectors); (iii) nutrient
per 1,000 livebirths in Cabo Delgado and Zambezia
deficiency (calories, proteins, and micronutrients,
respectively (1). Maputo city had a child mortality
such as vitamins and minerals; (iv) injury (acciden-
rate of 108 per 1,000 livebirths, and Maputo prov-
tal or intentional); and (v) personal illness control
ince had a child mortality rate of 103 per 1,000 live- (personal preventive measures and medical treat-
births. The report noted that the country had a po- ment). All the social and economic determinants
tential to achieve its overall 2015 targets for child of child mortality—the ’distal’ determinants—op-
mortality (67 per 1,000 livebirths) and under-five erate through these proximate determinants and
mortality (108 per 1,000 livebirths) (1). However, are grouped by Mosley and Chen into individual-
no breakdown for the child mortality and under- level, household-level and community-level vari-
five mortality targets by province was given. ables (5).
Table 1. Under-five mortality rates per 1,000 livebirths by province
1997 Mozambique 2003 Mozambique
Multiple Cluster
Province/region Demographic and Demographic and
Survey 2009
Health Survey Health Survey
Niassa 213 206 123
Cabo Delgado 165 241 180
Nampula 319 220 140
Zambezia 183 123 205
Tete 283 206 174
Manica 159 184 154
Sofala 242 205 130
Inhambane 193 149 117
Gaza 208 156 165
Maputo 147 108 103
Maputo city 97 89 108
National under-five
mortality rate 219 179 154
Source: Mozambique National Institute of Statistics, 2010
332 JHPN
Geographic differentials in mortality of under-five children in Mozambique Macassa G et al.
Niassa 66,580 19,330 52.1 206140 47 1.3 Contd.
9 5
n 0
rth regio Cabo Delgado 1,588,74 777,070 63.2 241178 56 4.1
o
N a 0 0
mpul 63,22 32,34 52.6 220164 42 6.0
a 5 8
N 3, 1,
a 0 0
mbezi 45,63 11,98 44.6 12389 47 5.2
Za 3,6 1,9
0
5 5
egion Tete 461,6 99,49 59.8 206125 46 1.6
al r 1, 7
ntr a 30 0
on Ce Manic 1,280,8 675,94 44.6 184128 39 2.8
gi 0
nce/re Sofala 582,26 90,270 36.1 205149 42 7.6
vi 1, 7
o
r e
p n 0
ators by nhamba 1,140,22 690,120 80.7 14991 33 1.3
c I
di 0
n 4 0
health i egion Gaza 1,333,5 647,32 60.1 15692 34 6.7
nomic and South r Maputo province 1,074,790 496,080 69.3 10861 24 0.5
o
d social, ec Maputo city 1,073,940 473,550 53.6 8951 21 0.8
e
ect al on 70
f sel tion milli 13,4 54 178124 41 4
n o Na 19 9,6
o
DistributiTable 2. Indicator Population–NIS projection for 2004 Children aged below 18 years (2004) % of population living below poverty-line (2003) Mortality Under-five mortality rate (2003) IMR (2003) Nutritional status (%) Chronic malnutrition among children aged 0-5 year(s) (stunting) (2003) Acute malnutrition among children aged 0-5 year(s) (wasting) (2003)
Volume 30 | Number 3 | September 2012 333
Geographic differentials in mortality of under-five children in Mozambique Macassa G et al.
a d.
Niass 25.1 30.2 70 11.1 46.6 51.9 Cont
n
h regio Cabo elgado 34.2 41.6 53.1 7.5 57.9 80.2
t D
r
o
N
a
ul
mp 28.2 32.2 26.2 8.1 53.9 69.1
a
N
a
zi
e 9 7 2 5 7 3
mb 26. 13. 19. 12. 44. 63.
a
Z
gion Tete 25.1 41.6 42.7 14.2 55 72
e
r
al
r
nt a
Ce Manic 22.9 47.1 45.6 19 61.6 81.5
a
ofal 26.2 47.7 28.8 26.5 63.9 74.7
S
e
n
a
amb 12.8 31.6 66 8.6 90.6 92.9
h
n
I
a 6 2 4 4 3 7
on Gaz 22. 50. 69. 16. 82. 91.
gi
e
r
h
Sout aputo ovince 9.2 48.9 90.2 17.4 92.5 96.9
Mr
p
o
aputcity 7.9 66.2 99.7 17.3 91.3 96.9
M
al
n 7 7 8 6 3 7
atio 23. 35. 44. 13. 63. 76.
N
—Contd.Table 2 Indicator Underweight children aged 0-5 year(s) (2003) Water and sanitation (%) Access to safe drinking-water (2003) Access to sanitation (2003) HIV/AIDSprevalenceamong persons aged 15-49 years (2002) Immunization (%) Children, aged 12-23 months, fully immunized (DPTHepB) (2003) Children, aged 12-23 months, immunized against measles (2003)
334 JHPN
Geographic differentials in mortality of under-five children in Mozambique Macassa G et al.
a
Niass 47.3 64.4 68 7.2 47 46 43
n
h regio Cabo elgado 60.6 68.4 83 5.9 31.4 29.6 43
t D
r
o
N
a
ul
mp 46.3 65.1 81.4 6.2 38.2 36.8 48.3
a
N
a
zi
mbe 59.8 61.4 80.6 5.3 32.1 32.7 39.4
a
Z
gion Tete 52.1 59.2 76.1 6.9 46.8 47.4 45.1
e
r
al
r
nt a
Ce Manic 67 45.4 64.5 6.6 55.9 56.0 63.6
s
c
Sofala 60.4 52.7 72.2 6 51 51.6 52.3 Statisti
f
o
ne te
a u
amb 74 46.5 57.9 4.9 49 49.8 32.9 nstit
h I
n al
I n
o
on Gaza 79.2 47.4 55.9 5.4 60.6 63.1 34.1 =Nati
gi IS
e N
South r Maputo province 86 28.6 38 4.1 85.2 85.4 53.4 tality rate;
r
o
m
Maputo city 84.5 15.1 22 3.2 89.2 90.1 61.8 nfant
I
=
R
M
ational 61 53.6 68 5.5 47.7 49 45.5 010. I
N 2
k,
—Contd.Table 2 Indicator Education and illiteracy (%) Primary net enrollment rate (2003) Adult illiteracy rate (2003) Female illiteracy rate (2003) Maternity care and adolescent fertility (%) Fertility rate (2003) Births attended by skilled health personnel (2003) Births in health institutions (2003) Communication Total % of population with radios (2003) Source: World Ban
Volume 30 | Number 3 | September 2012 335
Geographic differentials in mortality of under-five children in Mozambique Macassa G et al.
Although there is no general agreement on the Mozambique is predominantly a rural country,
theory for the relationship between the region of with 69% of the population living in rural areas
residence and under-five mortality (6,7), we hy- compared to 31% in urban areas. The country de-
pothesize that the province of mother’s residence pends on subsistence farming, and the agricultural
is a potential community variable that may reflect sector represents 20% of the total GDP of the coun-
the environmental, social and socioeconomic fac- try (4).
tors, which influence under-five mortality. In ad-
dition, we see the province of mother’s residence The population of Mozambique consists mainly
as proxy for inequalities in the underlying social, of indigenous tribal groups, such as Shangaan,
economical, cultural, ethnic and climatic factors Chokwe, Manyika, Sena, Makwa, and others. Eu-
but inequalities in provision of health services (in- ropeans comprise only 0.06% of the population,
cluding availability and access to health services Euro-Africans 0.2%, and Indians 0.08% (4,8,9). The
and medical assistance) are seen crucially. Thus,
official language is Portuguese but only 24.3% can
the province of mother’s residence would impact
speak and write in it. The majority of the popula-
under-five mortality in Mozambique through ma-
tion speaks one of the 13 national languages, with
ternal factors, such as age, parity, and birth inter-
Makwa (27.8%) and Tsonga (12.4%) being the
val; environmental contamination (water supply);
most common spoken languages. Islam is the pre-
health behaviours and practices; and use of health-
dominant religion in the Northern provinces and
care services.
in the central coastal area while the Catholic and
To the best of our knowledge, no study has at- the Protestant religions prevail in the South and
tempted to investigate the differentials in under- in the interior of the Central provinces. However,
five mortality by province in Mozambique to many Mozambicans are still Animist, believing in
date, although it is known that the country has Alma and Spirits (4,8). The country is divided into
experienced a very unequal geographical socioeco- three regions: North region (Cabo Delgado, Niassa,
nomic development. Therefore, as Mozambique and Nampula), Central region (Sofala, Zambezia,
progresses towards 2015, this study aims to assess Manica, and Tete), and South region (Inhambane,
the role of mother’s province/region of residence
Gaza, Maputo, and Maputo city) (9) (Fig.).
on the risk of under-five mortality.
Although Mozambique achieved a considerable
MATERIALS AND METHODS
economic growth in the 1990s, the benefits of
Study site economic development have not been distributed
evenly (4,8). Poverty remains endemic, and sharp
Mozambique, located on the east coast of south- inequalities exist in the country. For instance, in
ern Africa bordering Tanzania in the North, South 1997, the national Gini coefficient was 40, which
Africa and Swaziland in the South, and Zimbabwe, increased to 42 in 2002 (4).
Zambia, and Malawi in the West, is one of the poor-
est countries in sub-Saharan Africa (Development Study sample
Index of 165 among 182 countries in 2010) and in
the world (2). Data used in the study were drawn from the 2003
Mozambique Demographic and Health Survey
The number of inhabitants has increased from 16 (MDHS) conducted during August–December
million in 1997 to about 21 million in 2010 (2). 2003. The sample included 12,418 women aged
The provinces of Zambezia (Central region) and 15-49 years. Information was collected on birth-
Nampula (North region) are most populated, with
history, personal and household characteristics,
2,891,809 and 2,975,747 inhabitants respectively
health service-use, and child health at the time of
whereas Niassa (North region) has a population of
the survey. From the individual mother’s file, a
756,287 (2).
retrospective child’s file consisting of all children
Although Mozambique, since the end of the civil born to sample women was generated. Each live-
war in 1992, has had an annual economic growth birth and the subsequent health outcome contain
rate of 8% on average (4), the country is still very information on the household and parents. With
poor with a gross domestic product (GDP) of about this transformation, child’s records constituted the
PPP$ 900 per capita (1), and around 54% of the basic analytic sample. Since women may have had
population lives under the poverty-line (4). Life- multiple births before being interviewed, the child’s
expectancy at birth for both the sexes is 52.9 years file includes siblings.
(UNDP factsheet 2011), and the literacy rate is 54%
(69.5% for males and 40.1% for females). In 2008, For the purpose of the study, analyses were re-
the net rates of primary school enrollment were stricted to children born within 10 years be-
92% for male and 86% for female (2). fore the survey (n=10,326). The restriction served
336 JHPN
Geographic differentials in mortality of under-five children in Mozambique Macassa G et al.
Fig. Map of Mozambique Social and economic variables
The province of the mother’s residence was grouped
as follows: North region (Cabo Delgado, Niassa,
and Nampula), Central region (Sofala, Zambezia,
Cabo Delgado Manica, and Tete), and South region (Inhambane,
Niassa Gaza, Maputo, and Maputo city).
Religious affiliation of the mother was grouped as
Nampula Catholic, Muslim, Zionist, Protestant/Evangelic,
Tete and Animist/others. The place of residence was
classified into urban and rural, using de jure place of
Zambezia
residence (where the mother legally resides).
Parental education and occupation: In the MDHS
data (9), the parental education variable referred to
Manica Sofala
the highest level of education attained. There were
six categories, i.e. no education, primary incom-
plete, primary complete, secondary incomplete,
secondary complete, and higher education. For the
purpose of the study, three categories of the same
variable were created: (i) no education, (ii) primary
Inhambane
education, and (iii) secondary and higher education.
Gaza
There were 10 categories of parental occupation in
the MDHS, i.e. not working, professional, techni-
cal, clerical, sales, agricultural (self-employed), ag-
Maputo ricultural (employed), service, skilled manual work,
and unskilled manual work. For the purpose of the
study, the occupational categories were merged
into four groups: (i) professional; (ii) clerical, sales,
two purposes: (i) reduced recall error because the
service, and skilled manual worker; (iii) agricultural
quality of the birth-history information for recent
(self-employed), agricultural (employed), and un-
births was better than for more distant births and
skilled manual worker; and (iv) not working.
(ii) the assumption of a static risk profile using ret-
rospective data was least violated when using re- Wealth index: The 2003 MDHS also included a
cent births. The survey had a response rate of 82%. household wealth status index which was esti-
More details regarding the survey and its sampling mated from several household characteristics and
were reported in the official document of the 2003 asset variables, using principal component analy-
Mozambique Demographic and Health Survey (9). sis. The household characteristics used in estimat-
ing the household wealth index included having
Specification and measurement of
electricity, type of source of drinking-water, access
independent variables
to a sanitation facility, availability of cooking-fuel,
Demographic variables main roof-material, main wall-material, and floor-
material. The asset variables included durable
Sex of the child was classified as male or female. Age goods (wardrobe, table, chair or bench, watch or
of the mother at the child’s birth was grouped in 15- clock, radio, television, bicycle, motorcycle, sewing
18, 19-23, 24-28, 29-33, and 34+ years. Birth order machine, and telephone) and ownership of land.
and the preceding birth interval were merged into This household wealth index was used as a proxy
one variable (birth order/birth interval) to enable the indicator for household wealth status in the analy-
inclusion of first births in the analyses and were clas- ses. Household wealth inequality was measured by
sified into seven categories: (i) first births; (ii) birth dividing the wealth index into quintiles, with the
order 2-4 and short birth interval (<24 months), (iii) lowest quintile representing the poorest 20% of
birth order 2-4 and medium birth interval (24-47 households and the highest quintile representing
months), (iv) birth order 2-4 and long birth interval the wealthiest 20% of households in Mozambique.
(48+ months), (v) birth order 5+ and short birth in- More details regarding the wealth index in the DHS
terval (<24 months), (vi) birth order 5+ and medium can be found elsewhere (9,10). In this study, there
birth interval (24-47 months), and (vii) birth order are five quintiles: (i) the poorest; (ii) poorer; (iii)
5+ and long birth interval (48+ months). middle; (iv) richer; and (v) the richest.
Volume 30 | Number 3 | September 2012 337
Geographic differentials in mortality of under-five children in Mozambique Macassa G et al.
Household and environmental variables In the univariate model (with no adjustment for
any other variable) (Model I, Table 4), compared to
Three household and environmental variables, i.e.
children in Maputo province, those in the North
toilet facility, source of drinking-water, and type
provinces of Cabo Delgado, Niassa, and Nampula
of floor material, were used in the study. Three cat-
had a risk of dying which was 2.89, 2.11, and 2.35
egories were created for toilet facility: (i) flush toilet
respectively. In addition, compared to children
(own flush toilet, shared flush toilet); (ii) traditional
in Maputo city, those in the Central province of
toilet (traditional pit-toilet and latrine); and (iii) no
Zambezia had a risk of dying which was 2.43 times
toilet facility. For source of drinking-water, four
higher in Tete, 2.35 times higher in Sofala, and 1.81
categories were created: (i) piped water (piped into
times higher in Manica (Model I, Table 4). In the
own residence, piped into neighbour’s residence);
southern provinces, children in Inhambane had
(ii) public tap; (iii) well (well in residence, well in the
an under-five mortality risk which was 1.79 times
neighbour’s residence, public well); and (iv) others
higher than that of children in Maputo city (Model
(spring, river, lake, dam, rainwater). Type of floor-
I, Table 4).
material was categorized as: (a) natural (clay), (b)
rudimentary (wood and adobe), and (d) finished. Controlling for the demographic variables (Model
The indicators used in the study are described in II, Table 4), the socioeconomic and household en-
Table 3. vironment variables (Model III, Table 4) slightly re-
duced the risks obtained in the univariate analyses
Methods
but, overall, the mortality risks continued to be sig-
nificant. For instance, in Model II, the risk of under-
The dependent variable (outcome) was the risk of
five mortality for children in the northern province
death of under-five children (0-59 months), and
of Niassa decreased from 2.11 to 1.94 in Model III.
the main independent variable (exposure) was the
Furthermore, the under-five mortality risk for chil-
province of mother’s residence. Age of mother,
dren in the North province of Cabo Delgado de-
birth order, birth interval, age of child, place of resi-
creased from 2.89 to 2.80 in Model III (Table 4). This
dence, education of mother, occupation of mother,
pattern was also observed in the mortality risks of
religious affiliation of mother, source of drinking-
children in the Central and South provinces (Model
water, type of floor-material, and type of toilet facil-
II and III, Table 4). In the Central region, the mor-
ity were used as control variables.
tality risk in Manica province decreased from 1.81
To estimate the effects of mother’s residence on in Model I to 1.68 in Model III and in Sofala, from
the risk of mortality for under-five children, we 2.35 in Model I to 2.12 in Model III (Table 4). In the
used Cox regression analysis (11) in the SPSS soft- South, the under-five mortality risks decreased only
ware (version 17) (12), and results were expressed as slightly in Gaza province, from 1.79 in Model I to
mortality risk ratios with 95% confidence intervals 1.72 in Model III (Table 4).
(Table 4). Respondents with missing values were
DISCUSSION
excluded from the analysis. There were very few
missing values (Table 3).
The results of the univariate and multivariate
analyses showed a significant association between
The analyses were performed using three models.
under-five mortality and the region of mother’s
Model I dealt with the univariate relationship be-
residence. Children of mothers living in the North
tween under-five mortality and province of moth-
provinces (Niassa, Cabo Delgado, and Nampula)
er’s residence without adjusting for the influence of
and in the Central provinces (Zambezia, Sofala,
any other variables. In Model II, we adjusted for the
Manica, and Tete) had higher mortality risks than
demographic variables, such as age of mother, birth
children whose mothers lived in the South region,
order, birth interval, and sex of child. In Model III,
especially in Maputo province and Maputo city.
we further adjusted for the social and economic
However, within the South provinces, children
variables (urban-rural place of residence, parental
whose mothers resided in Inhambane province had
education and occupation, wealth index, and reli-
slightly higher under-five mortality risks than chil-
gious affiliation of mother) and the environmental
dren whose mothers were from Gaza and Maputo
variables (source of drinking-water, type of toilet
provinces.
facility, and type of floor-material).
RESULTS Similar patterns of regional differences in under-
five mortality have been reported in other devel-
Table 3 shows that children in the North (Niassa oping countries, especially in sub-Saharan Africa
and Cabo Delgado) and Central (Zambezia, Manica, (13-20). For instance, a study by Root in Zimba-
and Sofala) provinces had higher risks of mortality bwe reported that child mortality was 45% lower
than those in the South, particularly Maputo city. in Ndebele province than Shona province (18).
338 JHPN
Geographic differentials in mortality of under-five children in Mozambique Macassa G et al.
Table 3. Description of variables used in Cox Table 3.—Contd.
regression analysis of under-five morta- Variable No. %
lity by province of mother’s residence,
Sex of child
2003 Mozambique Demographic and
Male 5,139 49.8
Health Survey
Female 5,187 50.2
Variable No. %
Total 10,326 100
Province of mother’s
Socioeconomic variable
residence (region)
Place of mother’s
North region
residence
Niassa 837 8 Urban 3,639 35.2
Cabo Delgado 807 8 Rural 6,687 64.8
Nampula 1,174 11 Total 10,326 100
Central region Wealth index
Zambezia 952 9 Poorest 2,354 22.8
Tete 1,152 11 Poorer 1,848 17.9
Manica 1,042 10 Middle 2,113 20.5
Sofala 1,138 11 Richer 2,087 20.2
South region Richest 1,924 18.6
Inhambane 846 8 Total 10,326 100
Gaza 980 10 Education of mother
No education 4,273 41.4
Maputo province 715 7
Primary education 5,548 53.7
Maputo city 683 7
Secondary education 491 4.8
Total 10,326 100
Higher education 14 0.1
Demographic variable
Total 10,326 100
Mother’s age (years )
Education of father
at childbirth
No education 2,070 20.0
24-28 2,752 26.7
Primary education 6,036 58.5
18 and less 603 5.8
Secondary education 1,242 12.1
19-23 2,686 26.0
Higher education 49 0.5
29-33 1,993 19.3
Missing 922 8.9
34 and above 2,292 22.2
Total 10,326 100
Total 10,326 100
Occupation of mother
Birth order—preceding
Professional, technical,
birth interval months
managerial, clerical 131 1.3
Order 2-4 and medium Sales, service, skilled
interval (24-47 months) 2,978 28.8 manual 1,120 10.8
First births 2,353 22.8 Agriculture, household
chore, unskilled manual 6,867 66.5
Order 2-4 and shorter
Not working 2,206 21.4
interval (<24 months) 782 7.6
Missing 2 0.3
Order 2-4 and long
Total 10,326 100
interval (48+ months) 1,080 10.5
Occupation of father
Order 5+ and shorter
Professional, technical,
interval (<24 moths) 469 4.5
managerial, clerical 578 6
Order 5+ and medium Sales, service,
interval (24-47 months) 1,876 18.2 skilled manual 4,002 39
Agriculture, household
Order 5+ and long
chore, unskilled
interval (48+ months) 770 7.5
manual 5,059 49
Missing 18 0.1 Not working 110 1
Total 10,326 100 Missing 587 10.4
Contd. Total 10,326 100
Volume 30 | Number 3 | September 2012 339
Geographic differentials in mortality of under-five children in Mozambique Macassa G et al.
tion systems (1), which, in turn, may play a role in
Table 3—Contd.
the improvement of child welfare. Currently, half
Variable No. %
of the country’s population does not have access
Type of floor-material
to drinking-water and lacks adequate sanitation as
Natural (clay) 7,251 70.2
well. A 2006 study found that the South provinces
Rudimentary (wood and (Maputo, Gaza, and Inhambane) and Maputo city
adobe) 190 1.8 had the best access to the basic infrastructure and
Finished 2,629 25.5 services while the Nampula province in the North
Missing 256 2.5 and Zambezia and Sofala in the Central region had
the worst access (4). In Mozambique, there is an
Total 10,326 100
uneven distribution of the basic infrastructure, so-
Type of toilet facility
cial and economic factors, and healthcare (22). The
Flush toilet 183 1.7
distribution of some of these factors is shown in
Traditional toilet 5,615 54 Table 2.
No toilet facility 4,523 43.8
In the neighbouring country Zimbabwe, Root ar-
Missing 5 0.05
gued that the regional differences observed in child
Total 10,326 100
mortality could have been related to variations in
Source of drinking-water
the provision of healthcare and cultural factors
Piped water 1301 12.6
(18).
Public tap 953 9.2
Second, the differences in under-five mortality by
Well 4,048 39.2
province (region) of mother’s residence might be
Others 4,024 39
related to lack of satisfaction in the basic needs of
Total 10,326 100
the poor population, although since 2005, reports
Religious affiliation of of the Government on poverty reduction have
mothers
indicated that the levels of absolute poverty have
Catholic 2,620 25.4 declined (1,2). For instance, Silva stated that the
Muslim 1,532 14.8 South’s proximity to the Republic of South Africa,
Zionist 1,200 11.6 which provides a greater integration into the cash
economy, may increase the ability of southern
Protestant/Evangelic 3,136 30.4
households (Maputo province and Maputo city) to
Animist/others 1,838 17.8
accumulate more capital compared to the northern
Total 10,326 100
households, thereby contributing to inequality-
increasing effects of trade (19).
Furthermore, a study by Uwazurike found size-
able district-specific geographic variations in the
The third potential cause for the observed differ-
level of under-five mortality in Malawi, Nigeria,
ences in the mortality rates by province are the
Tanzania, and Zambia (21).
differences in cause-specific mortality. Although
the 1997 and 2003 Demographic and Health Sur-
The possible explanations for the observed differ-
veys did not collect data on causes of death, a re-
ences in the present study might be related to the
cent study by the United Nations Children’s Fund
following:
(UNICEF) found great differences in the distribu-
First, Mozambique has geographically been divided tion of the main leading causes of death (diar-
into three main regions (North, Central, and South) rhoea, HIV/AIDS, malaria, and acute lower respi-
but while this division was mostly derived from ratory tract infections—ALRI) among under-five
geographical and administrative factors, it had children by province (3). The study also found that
important implications on the economic struc- the Northern province of Cabo Delgado had the
ture of the country, with the South producing a highest mortality rate of diarrhoeal diseases (192
much higher share of value-added activities than per 1,000 people), followed by Zambezia province
the Central and North (4). Currently, the inequal- in the Central region with 169 per 1,000 people
ity gap in development between the three regions (3). Furthermore, the malaria mortality rates were
have somewhat increased, especially with the high in Zambezia (569 per 1,000 people) and Cabo
emerging of mega-projects, such as the Aluminium Delgado (539 per 1,000 people), and for HIV/AIDS,
Smelter Company and the Panda Gas in the South the highest under-five mortality was found in Gaza
of the country in recent years (1). This unequal so- province in the South (268 per 1,000 people), fol-
cial development has also been accompanied with lowed by Zambezia (237 per 1,000 people) in the
unequal distribution of the basic infrastructure, Central region. The mortality rates for ALRI were
such as schools, hospitals, and water and sanita- the highest in the Central provinces of Zambezia
340 JHPN