Understanding the Social Determinants of Health – Authors’ Response

We thank Priya Vart for critically reading our study
1
  • Balaj M
  • York HW
  • Sripada K
  • et al.
Parent education and inequalities in child mortality: a global systematic review and meta-analysis.

of the association between parental education and overall mortality in children under 5 years of age. Our models accounted for study-level controls for the confounding effects of wealth or income, partner’s years of schooling, and child’s sex. The main challenge with systematic reviews is that they are limited by the characteristics of the published study data, which limited our choice of covariates. This constraint brings us to a broader point, namely that to characterize the average effect of published studies, we had to choose an ideal study to effectively standardize all non-ideal studies. Our choice to report an unadjusted effect size for confounding by maternal age actually means that our reported effect sizes include the effect of maternal age on infant mortality as it operates across the parent education. Sensitivity analyzes (appendix 1 to article

1
  • Balaj M
  • York HW
  • Sripada K
  • et al.
Parent education and inequalities in child mortality: a global systematic review and meta-analysis.

pp 4–5) showed that incorporating additional study-level covariates using Demographic and Health Survey (DHS) microdata did not have a significant effect on our final estimates.

One way to estimate the magnitude of the effect of parental education after controlling for mother’s age is to take the coefficients reported in Table 3 of the article
1
  • Balaj M
  • York HW
  • Sripada K
  • et al.
Parent education and inequalities in child mortality: a global systematic review and meta-analysis.

and add the interaction of mother’s age with education. Rough estimates indicate that controlling for maternal age would dampen the annual effect of parental education on under-5 mortality for both mothers and fathers (reduced by 1.0% for mothers and 0.7% for fathers). However, mediation analyzes were not tenable with the data as published, and thus an analysis of the effect of maternal age, as it operates independently of parental education, was beyond the scope of this study. study.

We recognized the potential for geographic heterogeneity in the association between parental education and infant mortality.
1
  • Balaj M
  • York HW
  • Sripada K
  • et al.
Parent education and inequalities in child mortality: a global systematic review and meta-analysis.

We found no evidence of systematic variation between high-income and low-income countries, as approximated by limiting our study to DHS and non-DHS data (Appendix 1 to article

1
  • Balaj M
  • York HW
  • Sripada K
  • et al.
Parent education and inequalities in child mortality: a global systematic review and meta-analysis.

p 25). Our analyzes found evidence of variation between studies, which we interpret as variation between countries. In fact, we found that adding study-level variation to our estimates yielded a range of possible relative risks between countries between 39.0% and 23.0%, with our average global estimate being 31.0% (figure 6 of the article

1
  • Balaj M
  • York HW
  • Sripada K
  • et al.
Parent education and inequalities in child mortality: a global systematic review and meta-analysis.

). This variation is likely due to differences between countries in health care provision, quality of education, and other social determinants of health. Explanation of these factors should be encouraged in future research and may help identify opportunities for interventions to promote maternal and child health.

2
Women’s Political Empowerment and Child Health in the Age of Sustainable Development: A Global Empirical Analysis (1990-2016).

We declare no competing interests.

References

  1. 1.
    • Balaj M
    • York HW
    • Sripada K
    • et al.

    Parent education and inequalities in child mortality: a global systematic review and meta-analysis.

    Lancet. 2021; 398: 608-620

  2. 2.

    Women’s Political Empowerment and Child Health in the Age of Sustainable Development: A Global Empirical Analysis (1990-2016).

    Global public health. 2020; ()

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  • Parent education and inequalities in child mortality: a global systematic review and meta-analysis
    • To our knowledge, this study is the first effort to systematically quantify the transgenerational importance of education for child survival globally. The results showed that lower maternal and paternal education are two risk factors for infant mortality, even after controlling for other markers of family socioeconomic status. This study provides strong evidence for universal quality education as a mechanism to achieve Sustainable Development Goal target 3.2 to reduce neonatal and child mortality.

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    • I read the study by Mirza Balaj and his colleagues1 with interest. The authors are to be commended for their efforts to provide the most comprehensive data to date on parental education and infant mortality.1 It is often difficult to assess the role of socioeconomic determinants of health, which must be explicitly recognized. Balaj and colleagues found that parental age “runs the causal pathway between parental education and child survival” (i.e. education level determines the age at which a person becomes a parent).

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