1. Levels and Trends in Under-Five Mortality: An Empirical Evidence from Nigeria Demographic and Health Survey (2003-2013) ONI, Gbolahan A. 1 and ADETORO, Gbemisola W 2 Department of Econs & Development Studies College of Development of Development Studies Covenant University, Ota, Ogun State gbolahan.oni@covenantuniversity.edu.ng 1 gbemisola.adetoro@covenantuniversity.edu.ng 2 A Paper Presented at the International Conference on Demography and Sustainable Development gbolahan.oni@covenant THEME: DEMOGRAPHIC CHANGE AND SUSTAINABLE DEVELOPMENT DATE: JULY 14 TH -16 TH, 2014 VENUE: COVENANT UNIVERSITY, OTA

2. Introduction  Traditionally, high infant and child mortality had been a major reason why women produce many children with the expectation that some of them will survive. High fertility leads to rapid population growth which in turn is inimical to economic growth and development.  Reduction in mortality, particularly infant and child mortality had often led to decline in fertility and population growth rate which in turn enhances economic development now being experienced by the developed countries (Demographic Transition Theory)  Global under-five mortality rate for most regions between 1990 and 2012 has dropped from 90 deaths per 1,000 live births to 48 deaths per 1,000 live births respectively (United Nations Children’s Fund, 2013).  Under-five mortality rates in Africa varies, in some countries one-quarter to one-third of children die before reaching the age of five. Within the under-five age group, there are specific periods of increased vulnerability.  For instance, 60 percent of under-mortality can be attributed to death that occur during the first year of life, of which the first 24 hours of life is the most vulnerable period, followed by the first week and then the first month (Marx et.al, 2005).

3. Introduction (cont’d)  Globally, the four major killers of children under age 5 are pneumonia (18 percent), diarrhoeal diseases (15 percent), preterm birth complications (12 percent) and birth asphyxia (9 percent), while under nutrition is an underlying cause in more than a third of under-five deaths.  In the case of sub- Saharan Africa, malaria is a major killer, causing about 16 percent of under-five deaths (UNICEF, 2011).  A baby born in Nigeria was reported to be 30 times more likely to die before the fifth-year birthday than a baby born in a developed country (Policy project/Nigeria, 2002).  It is believed, however, that infant and child mortality in many developing countries, including Nigeria have been declining  Countries in sub-Saharan Africa that has made the most substantial progress in reducing their child mortality were those that have rapidly expanded public health at the basic level and developed nutrition interventions, such as immunization, breastfeeding, vitamin A supplementation, and safe drinking water (Policy Project, 2002).

4. Research Objective and Methods  Therefore, the aim of this study is to examine the levels and trends of under-five mortality in Nigeria and try to identify factors that might be associated with the movement using the Nigeria Demographic and Health Survey Data collected between 2000 and 2013.  Analysis of the levels and trends in childhood mortality and results presented here, make use of tables and graphical illustrations. Determinants of Under-five Mortality  Over one million children die annually in Nigeria from preventable diseases, thereby making the country one of the least successful of African countries in achieving improvements in child survival in the past four decades (WHO, 2012; Olumide & Odubanjo, 2009; Policy project/ Nigeria, 2002).

5. Determinants of under-five Mortality (Cont’d)  Although, considering the mortality trends in Nigeria since 1960, it can be deduced that under-five deaths are declining, but the rate of decline is relatively small compared to the MDG target of a two- thirds reduction by 2015 (Ojewunmi & Ojewunmi, 2012; Fayehun & Omololu, 2010).  According to Fayehun and Omololu (2009), child mortality in Nigeria has majorly been influenced by ethnics and regional disparities and these disparities are in form of mothers’ education, age at marriage, birth order, place of residence and wealth index.  Furthermore, Ogunjuyigbe (2004) reported that beliefs and behavioural practices play a significant role in determining child mortality. The study further shows that mothers do not have clear perception of illness and treatment, while some linked deaths of under-five to cultural beliefs.

6. Levels of Under-five Mortality in Nigeria  Table 1, shows that under-five mortality has reduced by 32% between 2003 and 2013. Though, there was a fall in the level of under-five mortality rate in the country, it is still below the targets stated in the Millennium development goals.  It can be established graphically that the fall in the rates of under-five mortality in the country within the 10 years period was not substantial. Table 1: Levels of Under-Five Mortality in Nigeria YEARRATE 2003187 2008157 2013128 Sources: NDHS 2003-2013

8. Mother’s Educational Attainment and Under-five Mortality  Studies have shown that there is a close relationship between educational attainment and lower child mortality rates (Ojewunmi & Ojewunmi, 2012; Fayehun & Omololu, 2010; Uddin, Hossain and Ullah, 2009; Olumide & Odubanjo, 2009).  This was further established through the findings in the NDHS Report (2008), that children born to mothers with no education have the highest under-five mortality rates (209 deaths per 1,000 live births), while mothers with secondary education have 68 per 1,000 live births.  Educated mothers are more likely than non-literate mothers to ensure a healthy environment, nutritious food, and have better knowledge about reproductive health at conception and health care facilities for their children

9. Mother’s Educational Attainment (Cont’d)  Research has shown that higher levels of education are associated with specific types of health knowledge, including awareness of the dangers of not boiling water, the importance of hand washing after latrine use, the proper use of oral rehydration therapy to treat diarrhea, and an understanding of contagions as a cause of disease (Frost et al, 2004).  Table 2, show the rates of under-five mortality by mothers’ educational attainments within the 10 years period. The table revealed that mothers with secondary and higher education reported lesser number of deaths compared to those with primary and no education.  Generally, there has been a decline in childhood mortality across all the educational categories during the 10 year period, however, the decline is much greater among children of mothers with no education or primary education than those whose mothers have secondary or higher education. The range for the decline is 33% for mothers with no education to about 20% for mothers with secondary education.

10. Mother’s Educational Attainment and Under-five Mortality (Cont’d) Table 2: Under-five Mortality Rate (per 1000) by Mother’s Education in Nigeria YEARS Mother’s Educational Attainment 2003 2008 2013 Percent Decline (2003-2013) No Education26920918033.1% Primary18615912831.2% Secondary1131169119.5% Higher Education80686222.5% Source: NDHS 2003-2013

12. Poverty and Under-five Mortality  Children from poorer or rural households are reported to be more vulnerable than their counter parts from other regions (UNICEF, 2010). A child born to a financially deprived and less educated family is at risk of dying perinatally or within the first month of life, since the mother was probably poorly nourished during pregnancy, had little or no antenatal care, and is unlikely to have delivered at a health facility.  Even though, the child is able to escape death in the first month, the child is then exposed to childhood illnesses, such as malaria and diarrhoea, due to poor living conditions, limited access to safe water and inadequate sanitation, malnutrition from household food insecurity, or ignorance about good child feeding practices (Policy project/Nigeria, 2002).  Figure 3, shows that the pattern of under-five mortality rates among women based on their wealth quintile had declined in all wealth status between 2003 and 2013. However, the rates of decline is much higher among lower wealth status than the high wealth status.  Though, there was an exception in the rates of women who were classified as richest, it was observed that in 2003 it was 79 deaths per 1,000 live births but increased to 87 deaths in 2008 and declined in 2013 to 73 deaths per 1,000 live births.

14. Access to Safe Water and Good Sanitation  Children in unhealthy or polluted environments are likely to be exposed to disease-causing agents, predisposing them to high mortality risks (Antai, 2011). Also increase in the prevalence rates of diarrhoeal diseases, cholera, and typhoid is seen in situations of unsanitary refuse, excreta disposal, and use of unsafe drinking water.  By close observation, figure 4a and 4b show that more households depend on borehole as source of drinking water. The percentage of households who depended on borehole rose from 38.2 and 22.4% among urban and rural dwellers in 2008 to 44.2 and 32% in 2013 respectively. While there was an increase among households who depended on borehole as source of drinking water in both centers, it was observed that the percentage of households that depended on pipe water, public tap and other sources had declined.

16. Vaccination  Figure 5, shows that the percentage of children who received DPT 3 over the 10 years period has increased. There has been an increase of more than 100% (i.e., 114%) in DPT3 coverage between 2003 and 2013. The DPT3 coverage in 2003 survey was 10.4% compared to 22.2% in the 2013 survey. It can be deduced therefore, the improvement in the level of vaccination may have contributed to the decline of childhood mortality especially from diseases and illnesses that are preventable.

17. Total fertility rate (TFR) and Contraceptive Prevalence Rate (CPR)  Decline in the total fertility rate cannot be underestimated, when discussing factors that has contributed to the current level of under-five mortality. In 2003 and 2008, TFR was estimated as 5.7 births per woman (figure 5). But in 2013, it was estimated as 5.5 births per woman which represented a 4% decline. Though, the magnitude of reduction was very small, but this can be linked to the increase in contraceptive prevalence between 2003 and 2013. This accounted for 15% increase, which might have contributed to the level of childhood mortality in the country.

18. Conclusion and Recommendations  Findings show that under-five mortality fell from 187 deaths per 1,000 in 2003 to 128 deaths in 2013 (a decline of about 32%). Mothers’ education was associated with decline in childhood mortality, however, mortality decline occurs across all educational groups of mothers.  Percentage of children who received DPT 3 increased from 10.4% in 2003 to 22.0% in 2013. This moderate increase in this essential routine immunization against childhood diseases could have contributed to decline in childhood mortality observed during the period reviewed.  Some improvement in the sources of drinking water with more people changing their drinking water source to bore hole and piped water from ”other” unsafe sources could contribute to reduction in childhood diarrheal diseases and hence reduction in childhood mortality.  Contraceptive prevalence rate increased from 13% in 2003 to 15% in 2013 and the TFR declined from 5.7 births per woman in 2003 to 5.5 in 2013. Improved contraceptive use will further lead to decreased fertility and consequently a greater decline in rate of population growth.  Family planning services and contraceptive use should be made more accessible and affordable to women.  Policy to improve the level of routine immunization of children such that most children complete the 3 doses of DPT will go a long way in reducing childhood mortality.  Finally, improvements in accessing good source of drinking water by households will help to further reduce under-five mortality.

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