Girls' hidden penalty: analysis of gender inequality in child mortality with data from 195 countries

Abstract

Introduction: Gender inequality has been associated with child mortality; however, sex-specific mortalities have yet to be explored. The aim of this study is to assess the associations between gender inequality and the child mortality sex ratio at country level, worldwide and to infer on possible mechanisms.

Methods: Data on sex-specific under-five mortality rates (U5MR) and the corresponding sex ratio (U5MSR) for the year 2015, by country, were retrieved from the Unicef database. Excess under-five female mortality was derived from previous published work. Gender inequality was measured using the Gender Inequality Index (GII). Additional biological and social variables have been included to explore potential mechanistic pathways.

Results: A total of 195 countries were included in the analysis. In adjusted models, GII was significantly negatively associated with the U5MSR (β=-0.29 (95% CI -0.42 to -0.16), p<0.001) and borderline significantly positively associated with excess under-five female mortality (β = 3.25 (95% CI -0.28 to 6.67, p=0.071). The association between GII and U5MSR was strong and statistically significant only in low-income and middle-income countries and in the Western Pacific area.

Conclusion: The more gender unequal a society is, the more girls are penalised in terms of their survival chances, in particular in low-income and middle-income countries. In order to decrease child mortality and excess girl mortality, global policy should focus on reducing gender inequality surrounding measures of reproductive health, women's political empowerment, educational attainment and participation in the workforce.

Keywords: child mortality; child mortality sex ratio; ecological analysis; gender inequality; gender inequality index (GII).

Figure 1

World map showing the under-five mortality rate per 1000 live births Sex ratio (U5MSR), adapted from Unicef. Categories calculated according to quartiles of distribution.

Figure 2

Scatterplot showing the association between the Gender Inequality Index (GII) on the X-axis and male (green) and female (blue) under-five mortality rate on the Y-axis, at country level, worldwide. Dotted lines show polynomial regression lines for boys and girls separately. U5MR, under-five mortality rate.

Figure 3

Scatterplot showing the association between the Gender Inequality Index on the X-axis and male to female under-five mortality rate on the Y-axis, at country level, worldwide, by country income categories. Dotted lines show polynomial regression lines for each category separately.