Understanding socio-economic determinants of childhood mortality: a retrospective analysis in Uganda

The socio-economic condition of the population is a major determinant of childhood survival at individual, household and community level [1, 2]. Social economic conditions influence the risk of childhood mortality by influencing intermediate or proximate variables such maternal factors, environmental contamination, nutrient deficiency, injury and personal illness control [3–8]. Childhood mortality is thus multi-factorial in causality, may have long latency periods between exposure and manifestation and thus the need for a multidisciplinary approach to understanding the causes and methods of alleviating childhood mortality is clear [9, 10]. Such an approach is also useful to understand the mortality disparities say between geographical regions and between different segments of the population [10]. Therefore an in depth investigation to connect ecological or socio-economic factors that may influence specific proximate determinants can give policy makers insights into development strategies that could reduce the differentials in childhood mortality [9–11]. Such an understanding could also lead to implementation of strategies/programmes aimed at a rapid decline in childhood mortality especially in low income countries where the rates are very high [11]. This approach may thus enable an acceleration of reduction in childhood mortality necessary to achieve millennium development goal number four (MDG4) especially in areas that face an uphill task in achieving the goal such as Uganda [12].

In this report we compared the childhood mortality in Teso sub-region of Uganda to the Ugandan national averages. We also analyse why Teso sub-region of Uganda appeared to have superior childhood survival indices compared to Uganda during the period 1959-1969. The period 1959 to 1969 was chosen because it was the most stable politically and most prosperous time during the history of Uganda [13]. Besides data for comparison during the said time was available (e.g.) from the 1959/69 census as well as from the 1962/63 and 1967/68 agricultural censuses [14–16].

The area under major food crops is shown in Table 4. In Teso 4746 km² (33%) of the land area was under food crops compared to 34902 (19.5%) for Uganda. The major crops grown in Teso were finger millet, sorghum, ground nuts and cow peas whereas the major crops grown in Uganda were bananas, cassava, sweat potatoes, maize and beans.

Table 5 shows the energy and protein content of major food crops that were grown in Uganda and how their availability varied for Teso compared to Uganda. Because the crops grown in Teso sub region were of high protein and high energy density the sub region had about 3 times the amount of protein and about 2.3 times the amount of calories compared to Uganda. These figures did not take into effect animal's sources of protein and energy but given the fact that Teso sub region had about 2.5 times the number of cattle compared to Uganda, one may assume that the diet in Teso was even richer than the average diet in Uganda.

These data show that childhood survival in Teso sub-region for the period 1959-1969 were superior compared to Uganda. The AARR between 1959 and 1969 of IMR (4.57%) for Teso was much higher than for Uganda (3%). It was also interesting to note that the AARR for Teso was more than the 4.4% required to attain MDG4 [12].

Our analyses also show that level of urbanisation was higher in Uganda compared to Teso sub-region. The level of education was also slightly better in Uganda compared to Teso. On the other hand total fertility was lower in Teso compared to Uganda. Furthermore, ownership of cattle and acreage under crops was much higher in Teso. Moreover, the crops grown in Teso were more nutritious being richer in protein, energy and in iron.

Because urbanisation and education were more favourable in Uganda compared to Teso we surmised that these indicators could not be responsible for the superior child survival in Teso. We instead hypothesized that the favourable indices related to ownership of cattle, differences in acreage under crops and in total fertility observed in Teso could be the ones responsible for the superior child survival. The low total fertility in Teso compared to Uganda has been linked to a cultural norm of prolonged breastfeeding that was estimated to last more than 2 years [15].

In this study we used ownership of cattle, land area under crops and availability of per capita protein and energy foods as proxy measures of socioeconomic wellbeing. This is because conventional measures of social economic status such GDP per capita and the gini coefficient were not available for Teso sub-region and for Uganda. However, such indicators are major determinants of social-economic status especially in agricultural communities of Uganda [21, 22].

Besides this analyses were based on retrospective data collected in censuses. It was therefore not possible to make comparisons regarding other causes of childhood survival such as access to health services.

The superiority of socio-economic characteristics of Teso sub-region were based on a peculiar farming system whose advantages could not be replicated anywhere in Uganda [18, 20]. The most distinguishing characteristic of the Teso farming system was the keeping of livestock and growing of high energy-protein crops, the two components being intricately integrated. This farming system was based on the use of ox-drawn implements, in a finger millet-cotton economy under a fairly high population and livestock density. Due to the use of animal draught, the system had the highest cultivated land per capita in the whole country, estimated at 8 acres per capita.

Thus the superior childhood survival indices in Teso sub region could be explained from several perspectives. First are the advantages of a cattle based mixed type of farming. Data from Uganda that analysed determinants of childhood mortality at household level has demonstrated ownership of cattle as major determinant of child survival [22]. The Livestock in Teso sub-region provided multiple benefits such as manure for improving soil fertility, animal traction and as source of cash all of which improves community wellbeing. Besides, because of livestock animal based traction men could take part in crop production through opening land. This would allow women particularly the pregnant and lactating women time for rest and more time to care for the children. Contemporary research point to the fact that as women are engaged in increased production relative to rearing of children, the benefits of increased production do not directly translate into well being of children [23]. Moreover, the use of animal draught, lead to higher productivity and easier opening of virgin land for agriculture meaning that fallowing was possible thereby allowing previously used land to rest and regain fertility [18].

Second the crops grown in Teso sub region had a very much higher density of protein and energy than those of Uganda meaning that malnutrition in Teso sub-region was much lower than the national average [18, 20]. The food in Teso sub region was also more likely to be complete with essential amino-acids such as lysine and methionine [20, 24] Furthermore, the major food crops produced in Teso (especially millet and groundnuts) were more likely to be stored for longer periods of time without being destroyed compared to major foods for the rest of Uganda. This increased food security in Teso and reduced the risk of food shortages [18, 20, 24].

The data suggest that mixed farming based on ownership of cattle, growing of high protein/high energy foods and semi-mechanization (as use of animal traction) may be an excellent combination to improve wellbeing of rural populations and accelerate the decline in childhood mortalities.