Background

The educational attainment of parents, particularly mothers, has been associated with lower levels of child mortality, yet there is no consensus on the magnitude of this relationship globally. We aimed to estimate the total reductions in under-5 mortality that are associated with increased maternal and paternal education, during distinct age intervals.

Methods

This study is a comprehensive global systematic review and meta-analysis of all existing studies of the effects of parental education on neonatal, infant, and under-5 child mortality, combined with primary analyses of Demographic and Health Survey (DHS) data. The literature search of seven databases (CINAHL, Embase, MEDLINE, PsycINFO, PubMed, Scopus, and Web of Science) was done between Jan 23 and Feb 8, 2019, and updated on Jan 7, 2021, with no language or publication date restrictions. Teams of independent reviewers assessed each record for its inclusion of individual-level data on parental education and child mortality and excluded articles on the basis of study design and availability of relevant statistics. Full-text screening was done in 15 languages. Data extracted from these studies were combined with primary microdata from the DHS for meta-analyses relating maternal or paternal education with mortality at six age intervals: 0–27 days, 1–11 months, 1–4 years, 0–4 years, 0–11 months, and 1 month to 4 years. Novel mixed-effects meta-regression models were implemented to address heterogeneity in referent and exposure measures among the studies and to adjust for study-level covariates (wealth or income, partner's years of schooling, and sex of the child). This study was registered with PROSPERO (CRD42020141731).

Findings

The systematic review returned 5339 unique records, yielding 186 included studies after exclusions. DHS data were compiled from 114 unique surveys, capturing 3 112 474 livebirths. Data extracted from the systematic review were synthesized together with primary DHS data, for meta-analysis on a total of 300 studies from 92 countries. Both increased maternal and paternal education showed a dose–response relationship linked to reduced under-5 mortality, with maternal education emerging as a stronger predictor. We observed a reduction in under-5 mortality of 31·0% (95% CI 29·0–32·6) for children born to mothers with 12 years of education (ie, completed secondary education) and 17·3% (15·0–18·8) for children born to fathers with 12 years of education, compared with those born to a parent with no education. We also showed that a single additional year of schooling was, on average, associated with a reduction in under-5 mortality of 3·04% (2·82–3·23) for maternal education and 1·57% (1·35–1·72) for paternal education. The association between higher parental education and lower child mortality was significant for both parents at all ages studied and was largest after the first month of life. The meta-analysis framework incorporated uncertainty associated with each individual effect size into the model fitting process, in an effort to decrease the risk of bias introduced by study design and quality.

Interpretation

To our knowledge, this study is the first effort to systematically quantify the transgenerational importance of education for child survival at the global level. The results showed that lower maternal and paternal education are both risk factors for child mortality, even after controlling for other markers of family socioeconomic status. This study provides robust evidence for universal quality education as a mechanism to achieve the Sustainable Development Goal target 3.2 of reducing neonatal and child mortality.

Funding

Research Council of Norway, Bill & Melinda Gates Foundation, and Rockefeller Foundation-Boston University Commission on Social Determinants, Data, and Decision Making (3-D Commission).

中文翻译：

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父母教育和儿童死亡率的不平等：全球系统回顾和荟萃分析

背景

父母（尤其是母亲）的受教育程度与较低的儿童死亡率相关，但全球范围内对于这种关系的严重程度尚未达成共识。我们的目的是估计不同年龄区间内与母亲和父亲教育程度提高相关的 5 岁以下死亡率的总体下降情况。

方法

本研究是对所有关于父母教育对新生儿、婴儿和 5 岁以下儿童死亡率影响的现有研究的全面全球系统回顾和荟萃分析，并结合了人口统计和健康调查 (DHS) 数据的初步分析。七个数据库（CINAHL、Embase、MEDLINE、PsycINFO、PubMed、Scopus 和 Web of Science）的文献检索于 2019 年 1 月 23 日至 2 月 8 日之间完成，并于 2021 年 1 月 7 日更新，无语言或发表日期限制。独立评审小组评估了每条记录是否包含有关父母教育和儿童死亡率的个人数据，并根据研究设计和相关统计数据的可用性排除了文章。全文筛选以 15 种语言进行。从这些研究中提取的数据与来自 DHS 的主要微观数据相结合，用于将母亲或父亲教育与六个年龄间隔的死亡率相关联的荟萃分析：0-27 天、1-11 个月、1-4 岁、0-4 岁、0 –11个月，以及1个月至4年。采用新颖的混合效应元回归模型来解决研究中参照和暴露测量的异质性，并调整研究水平的协变量（财富或收入、伴侣的受教育年限和孩子的性别）。本研究已在 PROSPERO 注册（CRD42020141731）。

发现

系统评价返回了 5339 条独特记录，排除后产生了 186 项纳入研究。DHS 数据根据 114 项独特调查汇编而成，涵盖 3,112,474 名活产婴儿。从系统评价中提取的数据与 DHS 的主要数据一起综合，对来自 92 个国家的总共 300 项研究进行荟萃分析。母亲和父亲教育的增加都显示出与 5 岁以下儿童死亡率降低相关的剂量反应关系，其中母亲教育成为更强有力的预测因素。我们观察到，受过 12 年教育（即完成中等教育）的母亲所生的孩子，5 岁以下儿童死亡率降低了 31·0%（95% CI 29·0–32·6），而母亲受过 12 年教育（即完成中等教育）的孩子的 5 岁以下死亡率降低了 17·3%（15 ·0–18·8) 父亲受过12年教育的孩子与父母没有受过教育的孩子相比。我们还表明，平均而言，受教育时间每增加一年，孕产妇教育可将 5 岁以下儿童死亡率降低 3·04% (2·82–3·23)，降低 1·57% (1·35)。 –1·72) 用于父亲教育。对于所研究的所有年龄段的父母来说，较高的父母教育与较低的儿童死亡率之间的关联都很显着，并且在出生后第一个月后最为显着。荟萃分析框架将与每个个体效应大小相关的不确定性纳入模型拟合过程，以努力降低研究设计和质量引入的偏倚风险。

解释

据我们所知，这项研究是首次系统地量化教育对全球儿童生存的跨代重要性。结果表明，即使在控制了家庭社会经济地位的其他指标之后，母亲和父亲受教育程度较低都是儿童死亡的危险因素。这项研究为普及优质教育作为实现可持续发展目标 3.2 降低新生儿和儿童死亡率的机制提供了有力的证据。

资金

挪威研究委员会、比尔及梅琳达·盖茨基金会和洛克菲勒基金会-波士顿大学社会决定因素、数据和决策委员会（3-D 委员会）。