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Reports from
Union of African Population Studies / L'Union pour l'Etude de la Population Africaine

1995
STATUS OF WOMEN AND INFANT/CHILD HEALTH IN KENYA WITH PARTICULAR REFERENCE TO THE HIGH MORTALITY ZONE IN NYANZA PROVINCE

Comprehensive Summary Report, Union for African Population Studies, 1995

STATUS OF WOMEN AND INFANT/CHILD HEALTH IN KENYA WITH PARTICULAR REFERENCE TO THE HIGH MORTALITY ZONE IN NYANZA PROVINCE

Monica A. Magadi

Population studies and Research Institute, University of Nairobi

Code Number: uaps95001

INTRODUCTION

Child survival is primarily determined by the social and economic status of the child's family, essentially expressed by two indicators - maternal education and some index of economic circumstances of the household (Mosley, 1985). Studies have confirmed that chronic malnutrition is linked to high rates of infectious diseases and child mortality. Differences in nutritional status are due to external circumstances, and not to ethnic differences in growth potential (Martorell and Habitch, 1986). these external factors include socio-economic differences, and regional and seasonal variations in anthropometric status (Brown et al., 1982). Repeated episodes of infectious diseases in conjunction with insufficient dietary intake are important factors leading to growth faltering in young children.

Infant and child deaths are the direct result of disease and malnutrition. Since death is the end result of a cumulative series of pathological processes, the biological status of surviving children reflects their position along the spectrum from good health to life threatening disability. The simplest indicator of this growth faltering and body wasting can be measured by relating height and weight to age (Mosley, 1995). After growth faltering in the first few years of life, there is rarely compensatory catch up growth later on (Sommerfelt, 1991). In most developing countries, diarrhoeal diseases are a leading cause of death of infants and young children, along with respiratory diseases and malnutrition. A study of the relations between protein-energy malnutrition and infectious diseases is fundamental for an understanding of the epidemiology of malnutrition (Scrimshaw, Taylor and Gordon, 1971).

Various studies in Kenya have confirmed the significant relationship between socio-economic factors and infant/child survival (Muganzi, 1984; Odhiambo, 1991; Ouma, 1991). Education is now recognised around the world as a basic prerequisite for development. There is a general consensus that the benefits of education, measured as increases in productivity and in overall quality of life, multiply with the increased participation of women and girls. Through education, households can learn what a balanced diet entails and parents can learn simple facts about child feeding practices and common childhood diseases. In Kenya, the major causes of infant and child deaths are malaria, acute respiratory infections, diarrhoeal diseases, and several vaccine preventable diseases. These diseases are often accompanied by malnutrition. In general, acute respiratory infections cause most child deaths in Kenyan highland areas while diarrhoea, malaria and malnutrition are the major causes of death in the low lying areas of the Coast and around Lake Victoria in Nyanza province (UNICEF, 1992).

This study examines the association between status of women and infant/child health in Nyanza province of Kenya based on the 1993 Kenya Demographic and Health Survey (KDHS) dataset and qualitative data. The specific objectives of the study were to: compare status of women and health status of children under five in selected districts in Kenya; establish association between demographic and socio-economic characteristics of women and health status of children aged under five years in Nyanza province; establish relationship between nutritional status and incidence of infectious diseases among children aged under five years in nyanza province; establish role played by traditional/religious beliefs and practices on status of women and infant/child health in the high mortality zone in Nyanza province.

Variables used as proxies of status of women include: women's education level, type of occupation, district of residence, membership to women organization, age at first marriage, marital status and current age. Infant and child morbidity is assessed based on anthropometric measurements and incidence of cough, fever and diarrhoea among children aged under five years. Methods of analysis involved: calculation of percentage distributions, cross tabulations including chi-square tests and Analysis of Variance (ANOVA). A comparative analysis was done for selected 15 districts adequately represented in the 1993 KDHS dataset, while a more detailed analysis focuses on Nyanza province. A further detailed investigation of how traditional values/beliefs and practices affect the status of women and infant/child morbidity is carried out in a high infant/child mortality zone. Information was obtained through carefully composed Focus Group Discussions (FGDs) comprising local women, members of women organizations, health personnel and religious groups in Ndhiwa division of South Nyanza district which had been identified as one of the areas with highest infant and child mortality rates. A total of 8 FGDs were conducted.

Successful planning and management of health services requires knowledge about the frequency and pattern of morbidity in a population, as well as the utilization of preventive and curative services. In addition, information is needed on the utilization of and attitudes towards other forms of health care. The findings of this research are expected to improve understanding of the association between the status of women and infant/child health and subsequent mortality. This will help health planners and policy makers as well as the local communities identify priority areas that need to be focused on with the meagre resources available.

District Differentials in Status of Women and Infant/Child Health in Kenya

Results indicate pronounced differentials in education and type of education between males and females in Kenya as illustrated in Table 1 below.

Table 1: District Differentials in Mean Number of Years of Formal Schooling and Percent in Professional or skilled occupation for Males and Females

District

Females

Males

 

Mean years of schooling

percent in prof./skil. occupation

n

Mean years of schooling

percent in prof./skil. occupation

n

Nairobi

Mombasa

Muranga

Nyeri

Kilifi

T. Taveta

Machakos

Meru

Kisii/Nyamira

Siaya

S. Nyanza

Kericho

Nakuru

Nandi

U. Gishu

Bungoma

Kakamega

8.91

8.22

7.49

7.99

6.42

7.31

7.09

6.54

6.95

6.55

6.02

6.66

7.24

6.71

6.68

7.10

7.37

17.7

15.3

5.0

12.0

7.1

9.3

6.4

4.4

3.1

4.8

8.2

7.1

7.9

4.5

2.2

4.3

7.6

367

372

361

367

337

281

438

364

488

408

257

322

252

403

315

396

372

10.08

10.73

9.87

8.55

8.42

8.14

7.96

7.79

8.03

7.42

7.29

9.13

8.09

7.14

7.83

8.37

7.94

46.3

58.0

32.1

36.9

30.2

38.9

35.3

16.3

30.5

30.5

30.3

26.9

38.0

21.0

22.2

26.8

31.2

229

226

224

217

258

180

309

257

325

295

218

216

179

262

185

280

263

In every district, the mean number of years of formal schooling was observed to be lower for females than males. The gender differentials in education varied considerably across districts, with districts like Kilifi, Muranga and Mombasa recording relatively low female:male mean years of schooling ratios, while relatively higher ratios were observed in Nandi, Nyeri and Kakamega. The mean number of years of formal schooling for females ranged from a low value of 6.0 years in South Nyanza district to a high value of 8.9 in Nairobi. Among the rural districts, the highest mean value was recorded in Nyeri (8.0 years). The results further showed that those districts with relatively low educational attainment for the females, are the same ones with greater gender differentials in education.

Marked gender differentials were also observed in type of occupation. While the percentage of females in skilled/professional employment varied from a low of 2.2% in Uasin Gishu district to a high of 17.7% in Nairobi, the percentages for males were several fold higher, with Nairobi and Mombasa recording values of over 45%. Among the rural districts, Nyeri recorded the highest proportion of females in skilled or professional employment (12.0%). The gender differentials in occupation varied across districts with Nairobi (0.35) and Nyeri (0.33) recording the highest ratios of female:male percent in skilled/professional employment while Kisii/Nyamira and Uasin Gishu recorded relatively low ratios of 0.1.

There were marked district differentials on infant and child health as shown in Table 2.

Table 2:Prevalence of Infectious Diseases and Malnutrition Among Children Aged Under Five Years for Selected Districts in Kenya

District

Percent of Children with:

Percent of children underweight

 

Cough & rapid breathing

Fever

Diarrhoea

 

Muranga

Nyeri

Kilifi

T. Taveta

Machakos

Meru

Kisii/Nyamira

Siaya

S. Nyanza

Kericho

Nakuru

Nandi

U. Gishu

Bungoma

Kakamega

22.8

16.4

17.6

22.8

18.4

17.5

17.9

21.0

15.4

14.7

12.9

14.5

16.7

16.3

17.5

48.7

30.4

46.0

36.8

42.2

18.4

38.0

55.6

53.8

35.9

37.5

30.4

27.5

47.0

47.3

7.8

9.3

18.0

4.6

14.9

10.6

10.6

20.3

19.5

11.4

12.0

9.9

7.3

17.4

22.7

28.0

21.4

51.3

41.6

39.9

38.4

29.2

24.2

31.3

44.3

27.5

28.8

33.2

26.5

25.9

Prevalence of infectious diseases among children aged under five in the two weeks prior to the survey show considerable variations by district. Highest prevalence of cough accompanied by rapid breathing was observed in Muranga, Taita Taveta and Siaya districts, all of which reported prevalence rates of over 20%. Relatively lower prevalence rates of below 15% were observed in Nakuru, Nandi and Kericho districts. Fever was most prevalent in Siaya and South Nyanza districts where more than half of the children were reported to have had fever in the two weeks prior to the survey. Diarrhoea prevalence varied from high rates of about 20% in Kakamega, Siaya, South nyanza and Kilifi districts to low rates of below 10% in Taita Taveta, Uasin Gishu, Muranga, Nyeri and Nandi districts.

Child malnutrition was observed to be a serious problem in Coast and Eastern provinces where all the districts adequately sampled appeared to have serious problems of child malnutrition.

Determinants of Poor Infant and Child Health in Nyanza Province

This section is based on multivariate Analysis of Variance (ANOVA), carried out to determine factors which have a significant effect on the nutrition and health status of children aged 5 years and below. Duncan's multiple range test is used to test for significance in differences between the main effect means. The effects (independent variables) examined in the analysis included: district of residence; age of mother; mother's education level; mother's marital status; mother's occupation; membership to women organization; parity; antenatal attendance; age at first marriage; father's education; father's occupation; and age of child. The dependent variables included: Height-for -age, Weight-for-height and weight for age z-scores, and incidence of diarrhoea, fever and cough accompanied by rapid breathing.

Inclusion of some important independent variables, such as preceding birth interval in the ANOVA model was hindered by some technical problems. Including preceding birth interval in the model would have an undesirable effect of automatically eliminating all first order births. Table 3 below gives the summary of ANOVA results.

Table 3: Summary of Determinants of Infant and Child Health in Nyanza Province - ANOVA Results

Dependent Variable

Dependent Variable

 

HAZ

WHZ

WAZ

Diarrhea

Fever

Cough

District of Residence

Age of Mother

Mother's Education

Marital Status

Mother's Occupation

Membership to WO

Parity

Antenatal Card

Age at First Birth

Father's Education

Father's Occupation

Age of Child

***

ns

ns

ns

***

ns

ns

ns

**

***

ns

***

*

*

ns

ns

**

*

*

ns

ns

ns

ns

***

*

ns

ns

ns

ns

ns

ns

ns

**

***

ns

***

ns

***

ns

ns

ns

ns

*

ns

*

ns

ns

***

***

*

ns

ns

*

*

ns

*

*

*

ns

***

ns

ns

ns

ns

*

ns

ns

ns

**

ns

*

***

Model

***

***

***

***

***

**

R2

0.22

0.18

0.21

0.12

0.19

0.09

N

777

782

776

834

831

828

Note:ns - not significant* - p<0.05** - p<0.01*** - p<0.001
HAZ - Height-for-Age Z-score
WHZ - Weight-for-Height Z-score
WAZ - Weight-for-Age Z-score

Nutritional Status of Young Children in Nyanza Province

Five of the independent variables were observed to have a significant effect on stunting levels of children in Nyanza province. These included; district of residence, mother's occupation, father's education, mother's age at first birth and age of child. These same variables, except mother's occupation, also had significant effects on the extent to which the children were underweight. Wasting among children was observed to be influenced by a slightly different set of variables. Apart from district of residence, mother's occupation and age of child, other factors observed to have significant effects on degree of wasting included; age of mother, parity and membership to a women organization. Table 4 below gives the mean Z-score values for main classes of the five most significant variables, based on Duncan's multiple - range groupings. Height-for-age, being a more reliable indicator of a child's nutritional status, has been used in Table 4 below.

Table 4:Mean Height-for-Age Z-score values arranged According to Duncan's Groupings for the Five most Significant Variables

Effect

Mean Height-for-Age Z-Score

No. of Children

 

Least Squares Mean

Simple Mean

 

1. District of Residence

- Kisii/Nyamira

- Siaya

- South Nyanza

2. Mother's Occupation

- Skilled/Professional

- Unskilled Employee

- Self employed

3. Age at First Birth

- 25 years and above

- Less than 15 years

- 20-24 years

- 15-19 years

4. Father's Education

- Secondary and above

- None

- Primary

5. Age of Child

- 0<1 year

- 4<5 years

- 2<3 years

- 3<4 years

- 1<2 years

 

-0.82

-1.04

-1.35

 

-0.64

-0.82

-1.13

 

-0.39

-0.94

-1.09

-1.04

 

-0.77

-0.70

-1.12

 

0.08

-0.93

-1.13

-1.16

-1.18

 

-1.13 A

-1.48 AB

-1.77 B

 

-1.03 A

-1.18 A

-1.66 B

 

-0.37 A

-1.36 B

-1.39 B

-1.46 B

 

-1.13 A

-1.26 AB

-1.59 B

 

-0.46 A

-1.48 B

-1.65 B

-1.71 B

-1.77 B

 

276

243

210

 

51

346

380

 

21

57

154

545

 

261

57

459

 

161

144

147

170

155

Note:Means with the same letters are not significantly different.

From the above table, it is evident that the nutritional status of children is affected by a number of factors ranging from geographical factors to socio-economic status of parents and demographic status of mother and child. Highest levels of nutritional status was observed among children in Kisii/Nyamira district, children whose mothers were in professional or skilled employment, whose mothers had their first birth at age 25 year and above, whose fathers had attained at least secondary level education and those aged under one year.

Incidence of Infectious Diseases among Children Aged Under Five Years in Nyanza Province

Almost all variables included in the model appeared to have some significant effect on the morbidity status of children as shown in the ANOVA results above. Mother's age, occupation and age at first birth, along with the child's age appeared to be of particular importance. Taking incidence of fever as an important indicator of infection among children, proportions of children having fever, arranged by Duncan's groupings are presented in Table 5 below for the significant variables.

Table 5:Proportion of Children Having Fever According to Duncan's Grouping for the Significant Variables

Effect

Proportion Having Fever 2 Weeks

Prior to Survey

No. of Children

 

Least Squares Mean

Simple Mean

 

1. District of Residence

- Siaya

- South Nyanza

- Kisii/Nyamira

2. Age of Mother

- 15-19 years

- 20-24

- 35+

- 25-29

- 30-34

2. Mother's Occupation

- Self employed

- Unskilled Employee

- Skilled/Professional

3. Membership to WO

- A member

- Not a member

4. Antenatal Card

- Do not have

- Have

5. Age at First Birth

- Less than 15 years

- 15-19 years

- 20-24 years

- 25 years and above

6. Father's Education

- Primary

- Secondary and above

- None

7. Age of Child

- 0<1 year

- 1<2 years

- 2<3 years

- 3<4 years

- 4<5 years

 

0.51

0.51

0.38

 

0.55

0.51

0.53

0.45

0.49

 

0.54

0.51

0.46

 

0.54

0.47

 

0.56

0.46

 

0.59

0.52

0.49

0.42

 

0.56

0.51

0.46

 

0.60

0.58

0.52

0.45

0.39

 

0.55 A

0.54 A

0.38 B

 

0.61 A

0.55 AB

0.46 B

0.45 B

0.45 B

 

0.53 A

0.46 B

0.45 B

 

0.53 A

0.45 B

 

0.63 A

0.48 B

 

0.60 A

0.50 A

0.44 AB

0.30 B

 

0.52 A

0.45 AB

0.41 B

 

0.58 A

0.57 A

0.48 AB

0.43 BC

0.37 C

 

253

218

302

 

36

219

136

233

207

 

394

383

54

 

393

438

 

38

793

 

60

574

174

23

 

488

279

64

 

173

166

158

179

155

Note: Means with the same letters are not significantly different.

Highest proportions of children with fever were observed among those who resided in Siaya and South Nyanza districts, whose mothers were aged below 20 years, self employed, member of women organization, did not have antenatal card and had their first birth before age 20 years, whose fathers had attained upto primary level education and infants aged under one year.

Demographic characteristics of the child and mother appeared to play a major role on prevalence of infectious diseases among children. While morbidity rates appeared to be higher for children of young mothers aged 15-19 years and older mothers aged 35 years and above, a negative association was observed between morbidity rates and mothers age at first birth as well as child's age. As mother's age at first birth and child's age increased, incidence of infectious diseases was observed to decrease. Fairly consistent patterns were observed, particularly in relation to incidence of diarrhoea and fever. The effect of socio-economic variables on prevalence on infectious diseases appeared less significant compared to the demographic factors.

It was surprising to note that the effect of mother's education on infant and child health was insignificant based on all indices used as indicators of child health, while the effect of father's education was significant. This unexpected finding may suggest that in Nyanza province, it is men who are probably mainly responsible for decision making in the households, including decision making regarding child care and child feeding practises.

It is evident from findings in this section that infant and child health in Nyanza province cannot be explained in terms of socio-economic and demographic characteristics alone. For instance, all the variables included in the ANOVA model only explain about 20% of the variation observed in nutritional status and incidence of fever as shown by the R2 values. The R2 value for diarrhoea and cough accompanied by rapid breathing was much lower. An in-depth investigation on the socio-cultural beliefs and practises is likely to shed more light towards better understanding of factors affecting infant and child health in the high infant/child mortality zone.

Association between Nutrition Status and Incidence of Infectious Diseases among Children in Nyanza province

A two-way cross tabulation analysis, including a chi-square test was carried out to determine the association between nutrition status (based on levels of stunting, wasting and underweight) and incidence of diarrhoea, fever and cough accompanied by rapid breathing among children aged under five years in Nyanza province. Children were classified into two categories based on each of the three indices of malnutrition. Thus, children were classified as either normal or stunted, wasted or underweight if their height-for-age, weight-for-height and weight-for-age Z-score values fell below minus two standard deviations from the reference population median. Table 6 below gives the proportion of children having diarrhoea, fever and cough accompanied by rapid breathing by the two categories of nutritional status.

Table 6:Proportion of Children Having Diarrhoea, Fever and Cough by Nutritional Status

Nutrition Status

Proportion of Children with:

Number of Children

 

Diarrhoea

Fever

Cough

 

Stunting

Normal

Stunted

Wasting

Normal

Wasted

Underweight

Normal

Underweight

 

0.17

0.21

 

0.18

0.24

 

0.16

0.25

 

0.49

0.50

 

0.49

0.55

 

0.48

0.55

 

0.23

0.23

 

0.23

0.21

 

0.22

0.24

 

561

353

 

809

105

 

668

246

A fairly strong relationship was observed between nutrition status of children and incidence of diarrhoea, based on all the three indices of child malnutrition. For instance, 25% of the children classified as underweight were reported to have had diarrhoea in the two weeks prior to the survey, as opposed to 16% among children classified as normal [p=0.003]. The relationship between degree of malnutrition and prevalence of fever was also positive, but less significant. No association at all was observed between nutrition levels and prevalence of cough accompanied by rapid breathing.

Status of Women and Child Health in Ndhiwa Division of South Nyanza District.

Despite the growing concern for gender equity, patriarchy appears to persist in most households in Ndhiwa division. Results from the Focus Group Discussions confirmed that there are jobs which are considered by the community to be exclusively within the male or female domain. The traditional division of labour in the households is far from equitable, burdening women much more than men. The low status accorded to women in Ndhiwa division is much tied to traditional beliefs and practises in the community regarding gender roles.

Health status of children in Ndhiwa was reported to be poor due to the high prevalence of different types of diseases, namely; malaria, diarrhoea and vomiting, measles and anaemia among others. These diseases were considered to pose serious threats to the lives of children in the area.

The tendency to attribute illness to socio-cultural and supernatural factors appeared strong. Due to this, there was a strong belief that some diseases, like measles, cannot be treated in hospitals. Even though poverty was believed to be the major factor responsible for

Results from analysis of both quantitative and qualitative datasets give clear evidence of low status of women in Kenya. The gender differentials in status vary considerably between districts, with the less socio-economically developed districts having the largest differentials. Nyanza province is one of the regions of the country facing most serious problems relating to women's status and health status of infants and children. Evident from the findings, is the marked district differentials within the province. While a district like Kisii/Nyamira may seem relatively advantaged compared to the rest of the province, some regions, particularly in South Nyanza appear to face serious problems which definitely call for special attention.

Infant and child health status is determined by a number of factors ranging from cultural and socio-economic status of the parents and community to demographic status of mother and child as well as availability, accessibility and use of basic services. The unexpected finding of an insignificant effect of mother's education on child health, as opposed to father's education may suggest that it is men who are mainly responsible for decision making right from household level. The findings of this study suggest that parents education has a positive impact on the health of their children only beyond primary level education. There is a strong positive relationship between undernutrition and diarrhoea prevalence among young children.

Findings from qualitative data analysis clearly illustrate the important role played by traditional beliefs and practises in determining women's status and subsequent child health in the high infant and child mortality regions of Nyanza province. The low status accorded women in some regions of the country is mainly related to traditional beliefs and practises in various communities regarding gender roles. Any attempt to improve child survival in these areas cannot ignore these beliefs and practises if significant steps are to be made towards achieving this important goal.

Apart from the important role played by traditional beliefs and practises in increasing problems related to infant and child health, equally important is the problem of availability, accessibility and use of basic services. Vital basic services like; transport network, hospitals/ Medical Health Centres, safe clean water, trained medical personnel, basic health facilities/ equipment and public toilets are either lacking or inadequate.

Based on the above conclusions, the study recommends that steps be taken to:

  1. Provide equal education and employment opportunities for both boys and girls. Particular emphasis should be given to girls' secondary education, especially in the less socio-economically developed districts.
  2. Improve child survival rates in Nyanza province through a combined effort to tackle problems resulting from both cultural and socio-economic factors. The community needs to be educated to appreciate modern health care and influenced to abandon, or at least modify some of their harmful traditional practises. In addition, vital basic services need to be made available and accessible to members of these disadvantaged communities.
  3. Launch intensive child health and nutrition education programmes in the area.
  4. Carry out An in-depth study on the effect of parents' education on infant and child health and survival.
  5. Undertake a comprehensive study on the role of women organizations in kenya on child survival.

REFERENCES

  • Brown K, R. E. Black, S Becker (1982)
  • "Seasonal Changes in Nutritional Status and the Prevalence of Malnutrition in a Longitudinal study of Young Children in rural Bangladesh. American Journal of Clinical Nutrition 36: 303-313.
  • Martorell R., J. P. Habitch (1986)
  • "Growth in Early Children in Developing Countries" Human growth: A Comprehensive Treatise Vol 3 ed. F. Falkner and J. M. Tanner, New york, Plenum press.
  • Mosley W. H. (1985)
  • "Will Primary Health Care Reduce Infant and Child Mortality - A Critique of some Current Strategies With Special Reference to Africa and Asia" in Jacques Vallin and Alan Lopez (eds) Health Policy, Social Policy and Mortality Prospects Ordina Editions.
  • Muganzi Z. (1984)
  • "Socio-economic and Environmental Factors Affecting Infant and Child Mortality in Kenya" Unpublished PhD Thesis, Florida State University.
  • Odhiambo S. A. (1991)
  • "Socio-economic and Health factors Affecting Child Survival in Bogusero sub-location of Kisii district" Msc. Thesis, University of Nairobi
  • Ouma F. O (1991)
  • "Environmental Risk and Socio-economic Factors Influencing Infant and Child Mortality in Siaya District" M. A. Thesis. University of Nairobi
  • Scrimshaw, N. S., C. E. Taylor and J. E. Gordon (1971)
  • "Interaction Between Nutrition and Infections" WHO Monograph No. 57, Geneva.
  • Sommerfelt A. E. (1991)
  • "Comparative Analysis of Determinants of Children's Nutritional Status" Demographic and Health Survey's World Conference Proceedings Vol. 2 Washington D.C.
  • UNICEF (1992)
  • Children and Women in Kenya, A Situation Analysis 1992 A Publication of the Government of Kenya and the UNICEF Kenya Country office - August 1992.

Copyright 1995 - Union for African Population Studies.

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