4.1 LA TRADICIÓN HISTÓRICA DEL AUTOGOBIERNO MITO Y REALIDAD.

Confounding factors are the variables which are associated with both independent and dependent variables and tend to confuse the relationship between them resulting in overestimation or underestimation of the effect sizes (Webb, 2011). It is critical in examining the association between a dependent variable and an independent variable to identify the factors that could have such confounding effects and address the issue through an appropriate analytical approach so that a net effect of the study factor can be elicited (Dargent-Molina et al., 1994). The literature review identified some confounding factors which are likely to influence the relationship between maternal education and child health outcomes.

2.3.2.1 Family income

Earlier studies conducted in Burundi and India indicated that the effect of maternal education on child mortality reduced by 50 percent when family income was adjusted by the analysis indicating that family income contributed half of the effect of maternal education (Goodburn et al., 1990; O'Toole and Wright, 1991). Based on a pooled analysis of nationwide survey data from 22 developing countries, Desai and Alva (1998) found that maternal education did not have an independent protective effect on child health outcomes as its effect became negligible when family income was controlled for in the analysis. Another multi-country analysis of 17 developing countries reported that the effect of maternal education on receiving the appropriate treatments for pneumonia and diarrhoea significantly reduced after controlling for family income indicating family income as a critical predictor of differential access and utilisation of child health services (Bicego and Boerma, 1993).

Mixed evidence was also found in relation to differential effects of maternal education across different income groups. Several studies conducted in India, Nicaragua, Lesotho and Latin America reported that the effect of maternal education had the highest impact on childhood mortality and stunting in the lowest income groups as demonstrated by its larger effect sizes compared to other income groups (Goodburn et al., 1990; Pena et al., 2000; Hatt and Waters, 2006; Ruel et al., 1992; Kikafunda et al.,

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1998). In a study in Bangladesh, Mahalanabis et al. (1996) asserted that maternal education in affluent households contributed to the reduction of infant mortality by four percent while its effect on poor households accounted for 35 percent reduction. Authors have suggested that ensuring universal attendance and completion of primary school among girls from poor households will revert one-third of child mortality in developing countries (Grepin and Bharadwaj, 2015).

Nevertheless, contradictory findings were reported in some other studies. In a study in Benin, Reed et al. (1996) claimed that an association was not found between maternal education and child health outcomes in the poorest and richest groups, while a strong and significant association was found with the intermediate-level income group. This finding indicated that the positive effect of maternal education brought its maximum impact when households had some level of resources, and it had less effect on the households with limited or ample resources. On the other hand, Dargent-Molina et al. (1994), based on a study conducted in the Philippines, also asserted that the protective effect of maternal education is greater among economically better-off mothers as compared to more financially disadvantaged mothers. Similarly, some multi-country analyses found that the effect of maternal education was more pronounced in better-off families than poorer ones implying that positive effects of maternal education on child undernutrition are apparent only when resources are adequate (Reed et al., 1996; Frost et al., 2005). A similar finding was reported in Latin America by Hatt and Waters (2006) in their analysis of the association between maternal education and child diarrhoea and pneumonia. In addition, the authors found that higher education in poor mothers returned less beneficial effects compared to the same level of education in rich mothers.

2.3.2.2 Geographical accessibility to health services

In the selected studies, geographical accessibility to health services was represented by urban/rural residence of the populations as a proxy. The urban/rural residence status was found as a confounder in the relationship between maternal education and child health as it contributed to the reduction of the effect sizes of maternal education on child health outcomes when it was adjusted by the multivariate analysis (Desai and Alva, 1998; Grepin and Bharadwaj, 2015; Makoka and Masibo, 2015; Onsomu et al., 2015). However, there were some variations reported by some of the selected studies. In an

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Indonesian study, Mellington and Cameron (1999) reported the variation of the maternal education effect between urban and rural areas: a year of maternal schooling contributed to reduction of child mortality by 1.7 percent in rural areas and 2.3 percent in urban areas implying its stronger effect in urban areas. Other studies, however, found that the effect of maternal education was weaker among urban populations, but it was stronger in informal urban slums and rural settings (Grepin and Bharadwaj, 2015). According to a study in India, analysing differentials of child health outcomes by geographical residence revealed that the rural-urban differentials were larger in the group of mothers with no or lower level of education whereas such differentials were smaller among mothers with higher education status (Gokhale et al., 2002).

2.3.2.3 Paternal (father’s) education

In some of the selected studies, paternal education was found to be confounding the effect of maternal education on child health outcomes (Vollmer et al., 2016; O'Toole and Wright, 1991; Breierova and Duflo, 2004; Becker et al., 1993). A study conducted in Bangladesh and India found that paternal education is more important than maternal education contributing more substantial independent beneficial effect on child health (Semba et al., 2008). The claim probably originated from the fact that, in most developing countries, the father is the only breadwinner in the family and father’s education represents social status which is directly related to family income. On the other hand, an Indonesian study indicated that both maternal education and paternal education exert the same level of independent effect on child health (Breierova and Duflo, 2004). Nevertheless, many studies argued that the effect of paternal education on child health was much lower than that of maternal education claiming that its effect was only half of the effect of maternal education in reducing child mortality and child undernutrition (Rao et al., 199; Akter et al., 2015; O'Toole and Wright, 1991; Desai and Alva, 1998; Semba et al., 2008). Macassa et al. (2003) reasoned that, compared to fathers, mothers in low-income contexts spend much of their time with their children as the main caregivers having better opportunity to contribute to health and wellbeing of their children.

49 2.3.2.4 Maternal reproductive factors

The review identified that women’s reproductive factors have confounding effects on the relationship between maternal education and child health. These factors include mother’s age at child birth, mother’s parity and birth interval between the children. Women under the age of 17 and those over 35 are denoted as high-risk mothers for pregnancy because of their increased risk of getting obstetric complications which could affect health status of both mother and child during pregnancy and childbirth (Jolly et al., 2000). The number of children ever born or parity of mothers is associated with major obstetric complications including pre-eclampsia which could result in increased risk of neonatal death (Ananth et al., 1996, Duckitt and Harrington, 2005). Birth interval between child births is also a critical maternal factor since shorter birth interval can have serious implications on the birth outcomes affecting both the health status of mother and newborn. It is recommended to have a minimum interval of 24 months between births since shorter intervals are associated with early childhood mortality and maternal mortality (Binka et al., 1995; WHO, 2015).

2.3.2.5 Other factors

Some of the selected studies used occupation of father and mother, living with mother-in-law in the same household, and age and sex of child as possible confounders of the relationship between maternal education and child health (Vikram et al., 2012b; Makoka and Masibo, 2015b; Devkota and Panda, 2016; Vollmer et al., 2016; Gupta et al., 2015; Streatfield et al., 1990; Becker et al., 1993b; Macassa et al., 2003b; Basu, 1994). The review found that the confounding effects of these variables on the relationship between maternal education and child health varies across different studies and child health outcomes. In most cases, there was a minimal reduction of the effect size of maternal education when these factors were controlled for by the analysis.