Analytical framework

The associations between the factors (bio-demographic, socio-cultural and economic, etc) that affect infant and child mortality are very complex. Consequently, it is necessary to develop an analytical framework in order to identify causal linkages and to understand the relationships between determinants that influence infant and child mortality. Various conceptual frameworks have been proposed and developed for the study o f child survival in developing countries. However, there is no general theory covering mortality during childhood and the mechanisms through which various determinants operate to influence child survival (Behm, 1991: 9).

The analytical framework used in this study is derived from several conceptual frameworks o f determinants o f child survival. These frameworks were developed by Mosley and Chen (1984), Mosley (1985), Jain (1985), Mahadevan (1986), Norren and Vianen (1986) and Shah and Shah (1990). The framework used takes in account the limitations o f the 1991 and 1994 IDHS.

Mosley and Chen’s (1984) conceptual framework is widely adopted by researchers studying child survival. This model assumes that health-related practices at the household level affect the survival of children under-five years old. Mosley and Chen use a set of intermediate variables which directly influence the risk o f morbidity

and mortality. They group 14 intermediate variables into five categories: maternal factors, environmental contamination, nutrient deficiency, injury and personal illness control. All social and economic determinants must operate through these variables to affect child survival. Mosley (1985) proposed a variation to this analytical framework: the most important change being the inclusion o f political and institutional factors such as a health program.

However, Jain (1985) argued that it is unnecessary to include all intermediate variables in the analysis, because the determinants o f child mortality depend on the age

of the child. According to Jain (1985), there are three different levels that affect infant mortality: community, household and individual. They are arranged in ascending order according to their proximity to the dependent variables. The individual-level factors are closest to the dependent variable, next come the household-level factors, and the community-level factors are the most distant. He assumed that the chance of infant survival is firstly dependent on the degree of care that the infant receives. Secondly, it is dependent on the physical, and social environment of the household. Thirdly, it is dependent on the social and economic environment at the community or village level.

Mahadevan (1986) and Shah and Shah (1990) introduced other broader theoretical frameworks for determining infant and child mortality. They link the political, social and economic policies, and conditions at national and international levels with household, individual and proximate factors affecting child mortality (Mahadevan, 1986; Shah and Shah, 1990). Norren and Vianen (1986) proposed a new model for the study of the malnutrition-infection syndrome and its demographic outcome (survival or death of children up to age five). Their model is based on fertility studies by Bongaarts and Potter (1983) and the work of Mosley (1985) on health and under five mortality. According to Norren and Vianen (1986), the intermediate

variables are both behavioral and biological factors which are classified based on the GOBI-FFF2 and child survival package program of UNICEF and WHO.

Figure 1 illustrates the broad conceptual model used in this study. It is assumed that the factors affecting infant and child mortality are different depending on the age of the child. In the proposed framework, the first level of the framework refers to the community and household characteristics related to socio-economic and environmental factors. The second level of the framework refers to the demographic characteristics o f the mother and index child in the study. The third level refers to the health care that is related to the pregnancy o f the mother and birth o f the index child. The last level refers to the survival of the child.

The socio-economic factors, maternal factors and dependent variables in the framework are those used by Mosley and Chen (1984: 27). The assumed directions of the relationships between the determinants of infant and child mortality are shown in Figure 1 by the arrows that connect the boxes. Individual factors, such as the size of the baby and whether the baby was bom prematurely and the health care received during the pregnancy are mostly related to infant mortality rather than to child mortality. In addition, other factors influence infant and child mortality. For example, vaccination of the pregnant mother against tetanus can virtually eliminate deaths from neo-natal tetanus. Proper medical care at delivery can also reduce the risk of death from birth injury and/or tetanus. Post-natal care, such as breastfeeding and immunisation, and timely and appropriate medical treatment in the case of illness can reduce the risk o f death during infancy. However, the only information available in this study is about the immunisation of living children not dead ones.

The new-born baby’s condition is influenced by intervening variables such as demographic factors (age of the mother at child bearing, birth order and length o f the preceding birth interval). The demographic factors are affected by variables at the

2 GOBI-FFF (Growth monitoring, Oral rehydration, Breast-feeding and Immunisation - Female education, Family spacing and Food supplementation) are primary health care strategies recommended by the UNICEF.

community and household level. Maternal age at child bearing, parity and preceding

o

birth interval are related to cultural factors which reflect the place o f residence and educational attainment of respondents. Other intervening variables, the sex of the child, survival status of preceding child and birth cohort are considered in the model as control variables. Sex of the child controls for biological effect, survival status of previous births controls for high risk mortality in the household while birth cohort controls for changes of mortality level over time.

Figure 1 Analytical framework for the study of infant and child mortality determinants in Indonesia

Household and Intervening Infant related Community factors variables care

Infant mortality

Child mortality - Size of the babies

- Premature/on time - Birth attendance - Pre-natal care - Post-natal care

- Sex of the child - Survival status of previous child - Birth cohort Demographic variables - Maternal age - Birth order - Birth interval Environment factors - Drinking water - Sanitation facilities - Housing factors - Province/ culture - Urban/rural - Parental education - Occupation - Socio-economic

The household and community factors reflect the environment in which a child is bom and raised. Household factors consist o f the environmental and socio­ economic condition of the households. Environmental contamination is conditioned by the quality of drinking water, the toilet facilities and the building materials o f the house. Socio-economic conditions are determined by parental education, paternal

occupation, parent’s ability to read letters and newspapers and speak Indonesian and the possession of a stove, television and electricity. The community factors are determined by the availability of infrastructure facilities such as medical services, water supply, school, transport and communication in the provinces. The use of these facilities varies between households in the same village or community. Therefore, the primary effect of these factors on infant and child mortality will be transmitted through changes in household-level factors. Furthermore, the effect o f community-level factors will be transmitted to the individual factors if entire households in the community are equally affected. For instance, if all pregnant women and children in the community were immunised, or if all o f the households in the community were consuming contaminated or clean water from the same source.

1.7

Organisation of the study

This study is organised into eight chapters. Chapter Two discusses methodology, data sources and data quality. Information about Indonesia and, in particular, health development is described in Chapter Three. Levels and trends of infant and child mortality are discussed in Chapter Four. Chapter Five deals with the survival function of infant mortality by socio-demographic factors. Chapter Six discusses a multivariate analysis of infant mortality using the Cox regression method. Provincial differentials of infant mortality are discussed in Chapter Seven. Chapter Eight concludes the thesis, makes policy suggestions and offers some suggestions to improve the measurement and analysis of mortality.

1.8

Summary

This chapter has highlighted the proximate determinants found by previous researchers. These determinants have a significant effect on infant and child mortality especially in many developing countries. The determinants o f infant mortality include not only proximate variables but also more complex factors such as government

expenditure in health sectors, government policy, the availability of community health services, health personnel and the culture of the people.

The level of measured infant and child mortality depends on the completeness and the reliability of the data, and also on the methods of estimation and statistical measurement. Chapter Two discusses data sources and the methodology used in this study. The fieldwork of the surveys, sample sizes, coverage of the surveys and quality of the data are discussed and examined in the next chapter. The justification for using the chosen methods of analysis as statistical tools for measuring the significance o f the parameters and the functional equations is also discussed in Chapter Two.

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