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. 2025 May 29;25(1):1976.
doi: 10.1186/s12889-025-23053-z.

From parental education to under-5 mortality: how antenatal care and hand hygiene mediate the pathway mechanisms

Tapas Mazumder  1 , Itismita Mohanty  2 , Danish Ahmad  2   3 , Theo Niyonsenga  2
Affiliations

From parental education to under-5 mortality: how antenatal care and hand hygiene mediate the pathway mechanisms

Tapas Mazumder et al. BMC Public Health. .

Abstract

Background: Reducing the under-5 mortality rate (U5MR) to as low as 25/1000 live births globally by 2030 to reach the sustainable development goal (SDG) 3.2.1 appears to be a race against time. Amidst this situation, Bangladesh experienced stagnancy in U5MR at the beginning of the SDG era. While a comprehensive understanding of this stagnancy is crucial, research on stagnancy is scant and limited to investigating the direct effects of the key predictors. Therefore, building on the existing evidence, this research investigated the effect of one of the key predictors, parental education, on under-5 mortality (U5M) mediated through antenatal care (ANC) and the availability of hand washing stations.

Methods: This study conducted weighted mediation analyses using the Bangladesh Demographic and Health Survey data from 2011, 2014 and 2017-18, with sample sizes 4,658, 4,367, and 4,826, respectively, and estimated a generalised structural equation model. The "nlcom" post-estimation command of STATA was used to obtain the direct effects (coefficients), which were then multiplied to estimate the indirect effects for the indirect parallel and sequential pathways. The indirect effects were added to obtain the total indirect effect, which was added to the direct effect of education to estimate the total effect of education.

Results: This study reveals inconsistent parallel and sequential mediation of parental education's effect across the three surveys. The direct effect of education on U5M reduced over time. The total (parallel and sequential combined) mediated effects of either parent's education on U5M were negative (reduced U5M risk). While the mediated effect of mother's education on U5M was not significant, the mediated effect of father's education was significant in 2011. The total effect of education (direct and indirect combined) on U5M was negative (reduced U5M risk) and significant in 2011. However, the effect reduced over time and changed direction in 2017-18. Since 2011, the effects decreased and changed direction to become positive (increased U5M risk) in 2017-18. Due to the weakening direct effect of education and the opposite nature of the indirect effect, the indirect effect of education appeared to be greater than the total effect in 2014 and 2017-18. In 2011, approximately 50% of the total effect of either parent's education was mediated. However, in 2014 and 2017-18, the proportions were greater than 100%, except for the proportion of the mediated effect of father's education in 2014.

Conclusions: This study reports a weakening and inconsistent mediated effect of both parents' education on U5M. Using existing literature, it also justifies that improving the quality of education and ANC could more effectively reduce U5M to achieve SDG 3.2.1. To improve the quality of education, this study recommends updating the school curriculum with a greater emphasis on maternal and child health education. To improve the quality of ANC, it is recommended that the mandatory use of ANC cards be strictly monitored.

Keywords: Antenatal care; Education; Handwashing; Mediation analysis; Stagnancy; Under-5 mortality.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate.: The de-identified data from BDHS 2011, 2014 and 2017–18 was accessed upon approval from the ICF. As these secondary data were nonsensitive in nature, the Research Ethics Committee of the University of Canberra exempted this study from the ethical review process (reference:11579). Consent for publication: Not applicable. Competing interests: The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
Sample selection procedure
Fig. 2
Fig. 2
Pathways of mother’s education to U5M mediated through ANC utilisation and/or hand washing station’s availability
Fig. 3
Fig. 3
Pathways of father’s education to U5M mediated through ANC utilisation and/or hand washing station’s availability
Fig. 4
Fig. 4
Pathways of mother’s education to U5M mediated through ANC utilisation and/or hand washing station’s availability (survey 2011)
Fig. 5
Fig. 5
Pathways of mother’s education to U5M mediated through ANC utilisation and/or hand washing station’s availability (survey 2014)
Fig. 6
Fig. 6
Pathways of mother’s education to U5M mediated through ANC utilisation and/or hand washing station’s availability (survey 2017–18)
Fig. 7
Fig. 7
Pathways of father’s education to U5M mediated through ANC utilisation and/or hand washing station’s availability (survey 2011)
Fig. 8
Fig. 8
Pathways of father’s education to U5M mediated through ANC utilisation and/or hand washing station’s availability (survey 2014)
Fig. 9
Fig. 9
Pathways of father’s education to U5M mediated through ANC utilisation and/or hand washing station’s availability (survey 2017–18)
See this image and copyright information in PMC

References

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