DETERMINANTS OF INFANT MORTALITY IN KENYA A HOUSEHOLD LEVEL ANALYSIS

By

SUSAN KABURA NGIGI

X50/64673/2010

Research Paper submitted to the School of Economics, University of Nairobi, in Partial Fulfillment of the Requirements for the Award of the Degree of Master of Arts in Economics

November, 2012

DECLARATION
I declare this research project is my original work which has not been presented for a degree award in this University or any other institution of higher learning. Where other peoples work has been used acknowledgements have been duly made.

SignatureDate. Susan K. Ngigi

We the undersigned have certified the students work and thus the project has been submitted with our approval as University supervisors.

SignatureDate. Prof. Jane Mariara

Signature..Date.. Dr. Mercy Mugo

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ACKNOWLEDGEMENT

I am grateful to God for the gift of life and for installing the seed of knowledge in me and more so for good health and energy to handle my studies well up to the end. To my loving mother for the sacrifice despite all the challenges, that ensured I attained basic education. To my sisters and brothers thank you for the support so far. God bless you all. This work received a lot of support from various people who in one way or the other guided and motivated me to the end. Special thanks go to my supervisors Prof. Jane Mariara and Dr. Mercy Mugo whose guidance and comments made this project a reality. I appreciate your patience and motivation. I also thank Dr. Wawire and Dr. Obere whose lectures on research methods helped me a lot in writing this paper. I am greatly indebted to the University of Nairobi for sponsoring my postgraduate studies which I could not have managed on my own. Special thanks also to the AERC also for facilitating the Joint Facility for the elective units. I also appreciate the School of Economics lecturers for their intellectual guidance in the field of Economics. To my classmates thank you for making the learning process enjoyable and for the valuable discussions. Special regards to Grace Njeri and Jane Kanina for academic and moral support and for their valuable input in this project. Finally my special recognition goes to my husband Geoffrey Muriuki for his valuable support throughout my entire study period. Thank you for your understanding, your financial and moral support; you made my learning easier and for this I salute you. God bless you abundantly and all the best in your studies too.

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DEDICATION
I dedicate this research project to my loving husband (Jeff) for your undying love, support and understanding throughout my Masters study. To our Angel Shikoh; your kicks in my womb kept me awake in the library and reminded me of the beauty of life. You greatly motivated my study. I wish you a long healthy life daughter.

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TABLE OF CONTENTS
DECLARATION.............................................................................................................................ii ACKNOWLEDGEMENT..............................................................................................................iii DEDICATION................................................................................................................................iv TABLE OF CONTENTS................................................................................................................v LIST OF ACRONYMS.................................................................................................................vii LIST OF TABLES ......................................................................................................................viii LIST OF FIGURES........................................................................................................................ix ABSTRACT....................................................................................................................................x CHAPTER ONE: INTRODUCTION..............................................................................................1 1.1 Project Background...............................................................................................................1 1.2 Statement of the problem.......................................................................................................5 1.3 Research Objectives...............................................................................................................7 1.4 Relevance of the Study..........................................................................................................7 1.5 Organization of the Study......................................................................................................7 CHAPTER TWO: LITERATURE REVIEW..................................................................................9 2.0 Introduction ...........................................................................................................................9 2.1 Theoretical Literature Review...............................................................................................9 2.1.1 Health care Production and child mortality framework by Mosley and Chen (1984)....9 2.2 Empirical Literature Review................................................................................................11 2.2.1 Studies Done in Kenya..................................................................................................11 2.2.2 Studies outside Kenya...................................................................................................13 2.3 Literature Summary.............................................................................................................16 CHAPTER THREE: METHODOLOGY......................................................................................18 3.1 Introduction..........................................................................................................................18 3.2 Analytical Framework ........................................................................................................18 3.3 Estimation Technique..........................................................................................................20 3.4 Variable Definitions.............................................................................................................21 v

3.5 Data Source and Analysis tool.............................................................................................24 CHAPTER FOUR: DATA ANALYSIS, RESULTS AND DISCUSSION..................................25 4.1 Introduction..........................................................................................................................25 4.2 Descriptive results...............................................................................................................25 4.3 Econometric analysis...........................................................................................................30 4.4 Discussion of Results...........................................................................................................33 5.1 Introduction..........................................................................................................................35 5.2 Research Summary..............................................................................................................35 5.3 Conclusion...........................................................................................................................35 5.4 Policy Implications based on key Results...........................................................................36 5.5 Limitations of the study.......................................................................................................37 5.6 Suggestions for further study...............................................................................................38 REFERENCES .......................................................................................................................................................39 APPENDIX ...................................................................................................................................42

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LIST OF ACRONYMS
WHO MDGs KDHs IMCI IMR DHS LPM LOGIT OLS HIV NFHS SRS KSPA World Health Organization Millennium Development Goals Kenya Demographic Health Survey Integrated Management of Childhood Illnesses Infant Mortality Rate Demographic and Health survey Linear Probability Model Logistic Regression Model Ordinary Least Squares Human Immunodeficiency Virus National Family Health Survey Sample Registration System Kenya Service Provision Assessment Survey

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LIST OF TABLES
Table 1.1: Some Health Indicators in Kenya (1990-2010)..............................................................2 Table 3.2: Variables Acronym Definition.....................................................................................20 Table3.3: Variable Definitions and Apriori expectation...............................................................22 Table 4.4: Infant Mortality Rate as per 2208 KDHs data..............................................................25 Table 4.5: Sample statistic on the Independent variables used in the study..................................26 Table 4.6: Mothers age in relation to Infant death.......................................................................27 Table 4.7: Mothers Education in relation to Infant death.............................................................28 Table 4.8: Other independent variables in relation to infant mortality..........................................29 Table 4.9: Results from Logit model for Infant mortality in Kenya.............................................31 Table 4.10: Marginal effects from logit models............................................................................32

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LIST OF FIGURES
Figure 1.1: Infant Mortality and Under-five Mortality trend in Kenya (per 1000 live births)......42

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ABSTRACT

The major objective of this study was to establish the determinants of health status in Kenya as proxied by infant mortality. The trend for infant mortality in Kenya has been on the decline but the levels are still high as compared to the MDGs target. Infant mortality rate is a good measure of economic development of a country as it indicates the quality of health services at a basic level and it is a sensitive indicator since infants depend on the socioeconomic conditions of their environment for survival. The study used individual household level data from the 2008 Kenya Demographic and Health Survey to examine the primary predictors of a child dying before celebrating their first birthday. The study employed a logit regression model due to the categorical nature of the dependent variable and also it was mostly used in literature by other researchers. Both standard coefficients and marginal effects are presented but the study discussion is based on marginal effects. Analysis of the study shows that in Kenya mothers age, household wealth, infants birth size, mothers education and tetanus Immunization were the major determinants of infant mortality. Based on the findings a number of policies are recommended which can help efforts in the reduction of infant mortality. To begin with the study recommends initiatives to encourage women to give birth at the middle ages, educating women past primary level, educating women on healthy lifestyle during pregnancy and the need to attend ante-natal clinic and to receive recommended immunization and improving households wealth standards would help reduce the probability of having high infant mortality rate in Kenya.

CHAPTER ONE: INTRODUCTION 1.1 Project Background

Health is a state of complete physical, mental and social wellbeing not merely the absence of disease or infirmity (WHO, 1948). According to the WHO declaration of Alma-Ata (1978), health is a basic human right and it is fundamental for sustained economic and social well being of a country. Attainment of a health level that will permit individuals to be socially and economically productive depends on co-operation between individuals and the government. The health status of a country is measured by the level of various indicators. The commonly used indicators of a society are life expectancy at birth, mortality rate and morbidity rate. Life expectancy at birth indicates the number of years a newborn infant would live if prevailing patterns of mortality at the time of its birth were to stay the same throughout its life (World Bank, 2008). Mortality rates refer to death rate. There are a number of different mortality rates namely; neonatal mortality rate, infant mortality rate, under five mortality rate, maternal mortality rate and crude death rate. Morbidity rates on the other hand refer to the rate of disease prevalence in a population (World Bank, 2008). Generally, health status indicators have been improving. However these indicators are still poor in developing countries compared to the similar indicators in developed countries. For example, life expectancy in Sub Saharan countries in 2007 was 49 years on average compared to 77 years in developed nations. Similarly infant mortality rates for the more developed nations was on average of 52 deaths per 1000 while for Sub Saharan countries was on average of 92 deaths per 1000 (Population Reference Bureau, 2007). An overview of Kenyas case is given in table 1.1 below

Table 1.1: Some Health Indicators in Kenya (1990-2010) Years Infant Mortality Under five Mortality Life Expectancy Fertility rate, Rate (per 1000 live Rate (per 1000 live at birth (total) total (births per births) births) woman) 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 64.3 66.1 67.6 69.1 70.7 71.8 72.6 72.7 71.8 70.2 68.6 66.9 65.5 64.2 62.8 61.4 60.0 58.8 57.3 56.3 55.1 99.4 102.7 105.4 108.3 111.6 114.2 116.3 117.2 116.4 114.0 111.1 108.1 105.3 102.7 100.1 97.5 94.6 92.1 89.3 87.0 84.7 59.3 59.0 58.5 57.8 57.0 56.1 55.2 54.3 53.5 52.8 52.3 52.0 52.0 52.1 52.5 53.0 53.7 54.4 55.1 55.8 56.0 6.0 5.8 5.7 5.5 5.4 5.3 5.2 5.1 5.1 5.0 5.0 5.0 5.0 5.0 4.9 4.9 4.9 4.8 4.8 4.8 5.0

Source: data.worldbank.org/data-catalog/world-development-indicators Table 1.1 shows trends in heath indicators in Kenya. There is remarkable improvement in child mortality since 1997 to 2010. At first infant mortality rate increased from 64 deaths per 1000 in 1990 to 72 deaths per 1000 in 1997. However after 1997 it has been on the decline up to 55

deaths per 1000 in 2010. In the same way, under-5 mortality rate increased from 99 deaths per 1000 in 1990 to 117 deaths in 1997 and has also been in a decline since then up to the level of 85

deaths per 1000 in 2010. The country is making progress in lowering the rates although 55 infants out of 1000 still die before celebrating their first birthday while 85 children out of 1000 die between one and five years of age. This implies loss in human capital which has negative impacts on a countrys future economic development. One of the Millennium Development Goals (MDGs) is the reduction of child mortality with a target of reducing child and infant mortality rate by two thirds between 1990 and 2015. Kenyas infant mortality rate was 64.4 deaths per 1,000 live births in 1990 (KDHS, 1993). To achieve the MDG goal 4 there is need to reduce infant mortality rate to 22 deaths per 1,000 live births by 2015. According to the World Bank data for Kenya, the infant mortality rate in Kenya for the year 2004-2008 was on average at 60 per 1,000 live births. This shows that despite the declining trends in infant mortality rates we are still very far from achieving the MDG goal. Kenyas first health framework; 1994-2010, lays out elements of a sound health care delivery system, capable of promoting health, preventing disease, promoting life and nurturing well-being to the highest possible health standards in response to the population needs. To meet its objectives, the government has implemented various interventions which target various determinants of health including nutrition, maternal education, safe water provision, adequate sanitation, proper housing, increased government expenditure on health, intervention on reproductive health services to control high population growth, and creation of a favorable environment for increased private sector, and community involvement in health service provision. Provision of insurance services was also expanded, with increased numbers of insurance firms and covered persons. In addition introduction of exemptions for user fees for some specific health services was done, including treatment of children less than 5 years, maternity services in dispensaries and health centers, TB treatment in public health facilities, and immunization services. Other interventions targeting infants included the malezi bora strategy which focused on child immunization, vitamin A supplementation, deworming of children under five years and pregnant women, treatment of childhood illnesses, management of HIV, ownership and use of treated mosquito nets for children and expectant mothers, preventive treatment of malaria during 4

pregnancy, and treatment of childhood fever. There was also the Integrated Management of Childhood Illnesses (IMCI) approach that looks at improving management and services in health care facilities as well as improving family and community health practices. Also there has been exclusive breastfeeding programmes (GOK, 2010). Despite implementing most of these policies, the health status indicators show a slow response in performance as shown in table 1.1. For instance according to the KDHS (2008) data, infant mortality dropped only by 32 percent in the 2008-09 survey as compared to the 2003 survey. This change is from 77 deaths per 1,000 to 52 deaths per 1,000. Correspondingly, the under-five mortality rate decreased to 74 deaths per 1,000 live births in 2008-09 from 115 in 2003 giving a 35.7% decline. However, the neonatal mortality rate only reduced by 6.1% from 33 to 31 per 1000 live births. Its effect on under five mortality increased to a contribution of 42% of the under five mortality compared to its contribution of 29% in 2003 (KDHs).

1.2 Statement of the problem

Kenya is committed to achieving the MDGs targets by 2015. Based on the success made so far, more progress could even be achieved despite the challenges. This study chose to examine the determinants of infant mortality in Kenya. The study focus was motivated by the fact that infant mortality rate indicates the quality of health services at a basic level and it is the most sensitive of all indicators since infants depend on the socioeconomic conditions of their environment for survival. Also, infant mortality has negative effects on a countrys future human resource thus ensuring infants health safeguards their future contribution to the economic well being both at home and nationally. Thus, the level of infant mortality would present a measure of how well a society meets the needs of its people (Bicego and Ahmad, 1996). Finally infant mortality rate illustrates the lasting impact of childhood health into adulthood. Childhood health has an impact on adult health, education, economic performance and social status which in turn impacts economic development of a country (Santere and Neun, 2010). There has been declining trends in infant mortality rates in Kenya since 1997. This decline has been attributed to the various interventions implemented in the health sector. However, despite the efforts by the government, these figures are still high as compared to the MDG target of 22 deaths per 1,000 specific for Kenya. Given this, we can hypothesize that there could be many 5

factors behind these low improvements in the health status that cannot be amended through increasing government health sector spending. There is need therefore, to establish the underlying factors and to point remedial measures which would work to alleviate the problem. Similarly there is need to focus on one particular area of concern which could have greater impacts on the infant mortality rates other than utilizing scarce resources on areas with very low impacts. For instance neonatal care, need receive more attention since it contributed 42% of the under five mortality as per KDHs data, (2008). A clear understanding of the determinants of infant mortality is therefore important which calls for deeper investigation of the determining factors of Infant mortality in Kenya. In Kenya the study done by Elmahdi (2008) considered socioeconomic determinants to be more important in determining infant mortality. His study was more concerned with the socioeconomic determinants. On the other hand Mutunga (2004) examined infant and child mortality relationship with households environmental and socioeconomic characteristics and found both as having significant impact on child mortality. Both studies used KDHS data for 2003. Wamae et al. (2009) assessed the health practices in the management of child illnesses in health centers and concluded health providers do not conduct full investigation and counseling of sick children and thus are responsible for the rising trends on child mortality. The study used KSPA data. This study has used recent demographic data KDHS (2008) which is more appropriate to consider after the major interventions mentioned above were implemented in the National Health strategic plan I and II (2000-2010). Also there was need to establish the important factors in infant mortality since each study reviewed focused on specific determinants of choice. This study therefore sought to fill this information gap in literature and make appropriate policies to our policy makers by estimating a model that has demographic, socioeconomic, biological, environmental, and maternal and child health care factors to establish which of them greatly determine infant mortality. This was aimed at helping the existing framework in order to stress the important of various factors in the mediation process for reducing infant mortality.

1.3 Research Objectives

The general objective of this study was to empirically examine the determinants of infant mortality in Kenya. The specific objectives were; 1. To investigate whether demographic, socio-economic, environmental and child/maternal health care factors have an influence on infant mortality. 2. To analyze the impact of mothers health knowledge on infant mortality. 3. Based on the findings in 1 and 2 above, to make policy recommendations aimed at reducing infant mortality rate in Kenya.

1.4 Relevance of the Study

This study was relevant as it will help add to the existing literature on child and infant mortality in Kenya. It used recent demographic data which was more appropriate to consider in assessing the impacts of various government interventions in child mortality. This is because earlier studies on infant mortality have used past KDHs data and there was need to use recent KDHs data for 2008 which is more appropriate to consider after the major interventions mentioned above were implemented in the National Health strategic plan I and II (2000-2010). This study has been done at the initial years of the implementation of the Kenya health policy plan 2010-2030 and in such; policy recommendation offered may help the government in its effort of reducing infant mortality with an aim of achieving the specific MDG target of 22 deaths per 1000 for Kenya by 2015.

1.5 Organization of the Study

In chapter one, the study presented the project background, problem statement, justification of the study and the study objectives. Chapter two reviewed both the theoretical and empirical literature relevant to this study. Chapter three outlines the methodological approach that was employed in this study and it includes the analytical framework, variable definition, estimation technique together with a description and analysis of data and data sources. Chapter four presents

results and interpretation of findings from the study. Finally, Chapter five gives a summary of the study, conclusions and policy implications.

CHAPTER TWO: LITERATURE REVIEW 2.0 Introduction

This chapter presents the theoretical and empirical literature on child health and mortality. Theoretical literature presents the health production model and child mortality framework by Mosley and Chen (1984), while the empirical literature discusses studies done on infant mortality in Kenya, other sub-sahara African countries and outside world.

2.1 Theoretical Literature Review

2.1.1 Health care Production and child mortality framework by Mosley and Chen (1984) Health care production according to Santere and Neun (2010) is influenced by a variety of inputs among them nutrients, genetic endowments, exercise, lifestyle and the amount of medical care consumed given the technological-biological production relationship. In household health production according to Rosenzweig and Schultz (1983) input preferences made by households are considered to be determined by the health technology. Health technology is the human biological mechanisms through which behavior affects health. The household preferences are also determined by prices and income of the household. They note that in order to conclude on causal relations between health and inputs there is need to control for heterogeneity and therefore estimate health technology from models in which inputs affecting health are choice variables by themselves. E.g mothers education This production framework was developed further by Mosley and Chen (1984) while trying to provide an approach to the investigation of determinants of child survival in developing countries. In their framework all economic, environmental and social determinants of child mortality operate through a common set of biological mechanisms (proximate determinants) to impact on mortality. For instance educated mothers may have lower infant mortality because the skills learnt will help them in making choices regarding contraception, preventive care, treatment and child nutrition. This model was first introduced by Davis and Blake (1956) in a study on fertility. The proximate determinants framework is very similar to the health production function for households.

The model identifies a set of proximate determinants that determine mortality directly. They are grouped into five categories. The first four categories affect the rate of a child moving from a state of healthiness to that of sickness while the last category; personal illness control, influence the rate of getting sick as well as the rate of recovery. This is through preventive measures and treatment seeking behavior. The categories include: Maternal factors (age, parity and birth interval); environmental factors (air, skin/soil, insect vectors, inanimate objects and food/water); nutrients deficiency (calories, proteins and the micronutrients); injury (intentional or accident) and Personal illness control (preventive measures and medical treatment). A change in any of the determinants will influence a childs health either to the better or to the worse. The Mosley and Chen (1984) framework was integrated by Shultz (1984) into an economic choice model. This model explores the biasness of the direct association between health inputs and an individual's health outcome as employed in epidemiological research. The argument is that individuals initial health endowment differs and their health inputs are determined by their knowledge of their endowment. The framework is based on the microeconomic model of the family. Individuals allocate their time and resources in response to the value of their time, nonhuman capital endowments and the relative prices for their inputs and outputs. The market determines the value of the time of persons working since the market sets the wage rate. Thus individuals allocate their resources to yield optimal quantities for all their choice variables for instance contraceptive use, nutrients intake, medical care, whether to breastfeed or not, food purchase and child care time for a given set of constraints; wages and prices and for a given production technology. Mothers education is used as a close correlate of women wages. This model gives two sets of equations and suggests methods of estimation for each. The first is the demand equation which predicts the proximate determinants as a function of cultural, social and economic factors. It can be estimated using OLS but for discrete choice variables, Logit or probit functions can be used. The second equation is the health production equation and it predicts the health outcome as a function of proximate determinants. It can be estimated using Logit or structural equation methods.

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Millard (1994) also proposed an approach to the investigation of determinants of child survival in developing countries. The model by Millard is similar to that by Mosley and Chen in terms of levels of causes of child mortality. However it differs by the introduction of three tiers of causes of child mortality in trying to emphasize parental behavior and child care traditions in the economic, social, cultural, political and environmental context. The three layers are proximate (immediate biomedical causes of death e.g. malnutrition), intermediate (behavioral patterns that increase exposure to the proximate causes e.g. breastfeeding patterns) and ultimate causes (economic, political and socio-cultural factors) According to Hill (2003), other modeling strategies have been in use after the Mosley and Chen model. For instance there are models that link background factors and proximate factors with mortality; such as factors related to immunization. The models are implemented step by step starting with background factors and then the proximate factors. A reduced-form model of net association of background variables and child mortality is then established. For example Ajakaiye and Mwabu (2007) have employed such a modeling strategy for the determination of birth weight while considering tetanus vaccination as a health input factor while behaviors like prenatal care and behavioral changes during pregnancy to be the intermediaries.

2.2 Empirical Literature Review

There are various studies regarding the determinants of infant mortality which show significant association between demographic, socioeconomic factors, environmental factors and infant mortality. 2.2.1 Studies Done in Kenya In Kenya there are several studies on infant and child mortality using KDHs and KSPA data. Kamau (1998) for instance used KDHs data for 1993 in his unpublished research paper focusing on child survival determinants in Machakos, Kilifi and Taita Taveta districts. The study showed significant relationship between marital status, mothers level of education, place of delivery, age at first birth, religion and availability of toilets with incidence of child mortality. Mutunga (2004) in his unpublished Masters research paper sought to show that socio-economic and environmental characteristics (mothers education, sources of drinking water, electricity, 11

cooking fuel and sanitation) have significantly varying impacts on mortality rates at different ages using KDHs data for 2003. The study employed hazard rate framework and considered a modified Shultz (1984) heath production theoretical framework. It concluded that both socioeconomic and environmental characteristics have significant impact on child mortality. In support of this argument is Kabubo-Mariara et al. (2012) whose study on child survival focused on the physical environment as a determinant of child survival and also used survival and asset index to analyze child poverty. The study used KDHS data for the period 1993-2003 while modifying the Mosley and Chen (1984) framework to a health production framework to model child survival. According to the findings, there exists significant relationship between physical environment and child survival with rural children being more subjected to poverty thus more likely to die than children living in urban areas. The study recommended improvement in children living conditions in rural areas through services like improved women education. Other contributions in the area of infant mortality are by Elmahdi (2008) who ranked the socioeconomic determinants of infant mortality at both urban and rural settings. His study concluded that the most important determinants of infant mortality was breast feeding, ethnicity, and fertility factors (birth order, size and intervals) and the least determinant was gender of the child. He used Logistic regression model. His motivation was on effective health interventions facing limited/competing resources by the government. Sharing this idea Oleche (2005), in his unpublished Masters thesis concluded that resources must be channeled towards primary and preventive healthcare and recommends the government to stop directing resources to areas with no direct or with little effect on social welfare. His study was on impact of health expenditures on health indicators (infant/under five mortality and life expectancy). In the study some of the government health expenditures were noted to have negative impacts on mortality. Wamae et al. (2009) motivated by the worrying trends in child and infant mortality in Kenya assessed the applicability of IMCI strategies in managing a sick child in health centers. They used data from the 2004 Kenya Service Provision Assessment Survey (KSPA). The autonomous variables used were facility in question (managing authority and type), region, qualifications and sex of the provider. According to their findings almost all providers interviewed did not conduct a full investigation and counseling of the sick child and thus could have contributed to the worrying infant mortality trend. Nurses and clinical officers were the worst in the management.

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The study suggests that improved skills for health workers are needed for better services in child health management. 2.2.2 Studies outside Kenya Studies done in regard to determinants of infant and child mortality globally show evidence of significant association between socioeconomic, demographic, environmental and infant-child characteristics (Hosseinpoor, 2005; and Caldwell, 1979). Caldwell (1979) for instance gave input in regard to effect of mothers education on infant mortality with reference to Nigeria. The study concluded that higher education lowered the rate of infant mortality through factors like hospital delivery, increased ante natal care for pregnant mothers and changing traditional family relationships. Supporting Caldwells explanation, Hobcraft (1993) explained that education can contribute to child survival by making women more likely to marry and enter motherhood later, have fewer children, utilize prenatal care and immunize their children. Maternal education is usually used as a proxy for other household characteristics. Medrano et al. (2000) used mothers education as a measure of health knowledge and the socioeconomic status. Their study used cross sectional data for South Africa Integrated Household Survey for 1993. They used nave regression to assess the relationship between mothers education and child health and the findings show positive relation with increased knowledge leading to childs good health. Similarly Kovsted et al. (2003) using mothers religion as a measure of health knowledge showed mothers knowledge was important in determining child health. In another level, mothers education has been shown to have positive and inverse impact on child health. Desai and Alva (1998) using DHS data from 22 countries found that infant mortality was lower among educated women, and that although this effect intensify with the inclusion of other socioeconomic factors in their models, maternal education remained significant. In contrast, Hill et al. (2001) observed an inverse relationship between mothers educational level and economic status and child mortality in the late 1980s and 1990s using the 1993 and 1998 Kenya DHS data. This study was done using multivariate analysis. The variables examined were mothers education, wealth status, residence, maternal age, preceding birth interval and birth order. The authors made a conclusion that HIV epidemic was the most probable cause of increased child mortality not the socioeconomic or demographic factors. 13

Beenstock and Sturdy (1990) also found important role for female literacy in determining infant mortality in their study among several Indian states. However the study concluded that maternal literacy had a weaker effect on child survival in Sub-Saharan Africa. This could be due to environmental factors, family wealth and other demographic factors unique to this part of the continent. Similarly in India Claeson et al. (2000) analyzed the countrys SRS and NFHS data and observed that non income factors (maternal and child health interventions) play a significant role in reducing infant and child mortality in India. The study also observed that girls are 30 percent more likely than boys to die before their fifth birthday. This was attributed to son preference in India, which is manifested in lower spending on health for girls and higher prevalence of immunization among boys. Conversely the United Nations secretariat (1988) carried out a study on sex differentials on life expectancy and mortality in less developed countries and their results showed that male infant have higher probability of dying than female infants. According to Jones et al. (2006) the main causes of child mortality presented in India are disease related (diarrhoea, pneumonia for under-five children and tetanus for new born), pre-term delivery and sepsis. However the major cause of death is under nutrition. Due to inadequate data the study employed an analytical overview through study groups. While Uganda DHS for 3 surveys and employing a reduced form probit model, Ssewanyana and Younger (2005) investigated the infant mortality determinants in Uganda in order to assess the likelihood of Uganda meeting MDG goal 4. The results show that improvement in mothers primary education and vaccination service greatly impacts infant mortality. However household income and infant mortality were correlated negatively to a small extent. This implied that even if Ugandas rapid growth continued the impact on infant mortality would be small. A study by Hosseinpoor et al. (2005) on the socioeconomic inequality in infant mortality in Iran using ordered probit model concluded that other factors beyond the health care delivery system significantly contribute to high infant mortality rate in Iran. The study recommended additional interventions to be done in the area of environmental and sanitation in order to reduce infant mortality. This would work best if implemented in rural areas so as to curb the socioeconomic inequality in mortality among urban and rural areas in Iran. The study used DHS data done in

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Iran in 2000. This data covered a long period of time (early 1980s to early 2000s). Alves and Belluzzo (2005) investigated the determinants of infant mortality rates in Brazil using panel data for the years 1970, 1980, 1990 and 2000. Pooled OLS was used to estimate the model while considering variables like sewage services, illiteracy rates and dummy variable for economic development. Their findings confirm that poor child health (in terms of mortality rates) in Brazil could be explained by the levels of education, sanitation and poverty. Moreover, the paper showed that mothers education was the most important variable given that for every additional year of schooling, average mortality rates declined by more than 7%. Pandey, et al. (1998) estimated the socioeconomic determinants of infant mortality and observed that mothers literacy, household heads religion, place of delivery, cooking fuel, mothers exposure to mass media and wealth were significant variables. However religion was found to have a modest impact in some region of Iran. Hazard models were used to analyze the relationship using NFHS data. Mothers tetanus immunization during pregnancy was also found to reduce neonatal mortality. In another level, the study also found a U-shaped relationship between birth order and mothers age at birth with infant mortality. Thus when age increases from teenage to matured mother mortality falls and it rises as one move to elderly mother. Other studies have also documented evidence of a reverse pattern in the association between maternal age at birth and infant mortality, with teenage and older mothers having elevated risks of child loss (Koenig, 1992; Pebley, 1991). A study by Da vanzo et al. (2004) supports these findings. They used high-quality longitudinal dataset in Bangladesh to establish the relationship between birth interval and child mortality. The findings using Cox proportional hazard model show that preceding inter-birth intervals of less than 24 months in duration are associated with significantly higher risks of early neonatal mortality whereas, intervals of less than 36 months are associated with higher risks of late child mortality. Effects of short intervals are stronger the younger the child. Madise, (2003) did a study which aimed at comparing the socioeconomic and demographic determinants of child mortality in Zambia and found that at neonatal stage demographic factors

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(e.g. birth orders, mothers age ) were more important determinants of infant mortality while at the post neonatal stage both demographic and socioeconomic e.g. place of residence, were important determinants. Several studies have considered households socioeconomic status in terms of their source of drinking water, sanitation, source of cooking oil and income level. Where data on income levels is not collected it is proxied by wealth. According to Mosley and Chen (1984) the effect of socioeconomic factors on mortality is through environmental hazards, maternal factors, injury and nutritional status. Kabubo-Mariara et al. (2012) shows that water and sanitation variables reduce the hazard ratio when other factors affecting mortality are not controlled but when controlled the variables gave a positive relationship with mortality. Fayehun (2010), hypothesized that variations in household environments among sub-Saharan countries could affect childrens survival chances. The study found that there are significant relationships between the household environment and child survival. Some of the differences in childhood mortality could be explained by levels of household environmental health hazards and by maternal socioeconomic status. Source of cooking fuel is another considered variable that affect child mortality. Mutunga (2004) found clean sources of cooking fuel to be significant in reducing death in households. This could be due to a reduction in indoor air pollution.

2.3 Literature Summary

In conclusion, major health determinants that have been put forward in literature are socioeconomic, demographic and environmental factors. Also health services and behavior that promote and increase health stock have been associated with improved health status. For instance tetanus injection for pregnant mother, higher education/health knowledge for mothers, access to clean water and sanitation were found to have high impacts on child survival. In another level, high mortality rates were observed in girls than boys due to some households preference of boys. Therefore there are many factors that have been argued to be the determinants of infant mortality. The choice of variables used in the present study was determined by data availability.

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Nevertheless most of the determinants of infant mortality presented in literature, like mothers age at the time of birth, mothers education, place of residence, religion, household wealth, birth interval, access to sanitation, source of drinking water and tetanus injection of mothers were analyzed. Majority of the studies reviewed in Kenya were mainly concerned with some determinants not all. For instance, Mutunga (2004) was concerned with impacts of environmental and socioeconomic factors on child mortality, Kabubo-Mariara et al. (2012) focused on effect of physical environment on child survival while Elmahdi (2008) was more concerned on the socio-economic determinants of infant mortality. On another level Kamau (1998) focused on child survival determinants in arid and semi arid lands of Kenya thus did not consider the whole country. This study will add to the existing knowledge on child mortality in Kenya while employing a model that incorporates most of the variables available in the socio-economic, demographic, environmental and biological categories as well as maternal and child health care factors to establish which of them greatly determine infant mortality.

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CHAPTER THREE: METHODOLOGY 3.1 Introduction

This chapter presents the tools of analysis and describes the data as well as methods of analysis that will be used. The methodology of the study was motivated by the reviewed literature both theoretical and empirical in chapter 2 and the type of data that is available.

3.2 Analytical Framework

From reviewed literature child/infant survival was found to be determined by socioeconomic factors which affect the intermediate/proximate determinants of health. These proximate determinants are the intermediate variables between the socioeconomic determinants and the mortality risk (Mosley and Chen, 1984). The variables include; (maternal and environmental factors, nutrient deficiency, injuries and disease control). In this regard the household production framework given by Schultz (1984) will be modified and used to analyze the impacts of various covariates on child survival. As Hill (2003) puts it; this framework has stood the test of time and still provides the conceptual basis for many studies on child survival. For instance this model was modified and used by Mwabu (2008) in his study of child health production in Kenya and Foloko (2009) Masters thesis on determinants of child mortality in Lesotho. Child health production function is given as a linear function; H = F (Y, I,k, )..(1) Where, Y is the proximate biological inputs to child health (immunization, cooking fuel, water and sanitation environment) I is a child health input such as curative and preventive medical care K is the health knowledge possessed by the household (e.g. fertility and child spacing techniques) and is the child health endowment due to genetic or environmental conditions not influenced by the parents.

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The proximate inputs Y are chosen by the household in a manner to reduce the health outcome (mortality). They depend on the child health endowment (), maternal/household preferences (PR), prevailing prices in the market and specific constraints posed by the households physical environment (P) and household wealth (W). Thus our reduced-form input demand function will be; Y=F (, PR, P, W).. (2) The reduced form demand functions were given as the objects of study in the Shultz (1984) model. Equation (1) and (2) shows that child health can be explained by proximate biological inputs to child health (Y), child health input (I), Household knowledge (K), household wealth (W), and a childs health endowment . Based on equation (1) and (2) this study estimated a model which included variables from the categories in the equations. The choice of variables was motivated by the Mosley and Chen (1984) framework. These factors consisted of; Xi,j which is a vector of maternal characteristics (maternal age, education, religion, number of children ever had, marital status and family/residential factors). This was to help capture the households choice of proximate inputs and its impact on mortality. Xk,j which is a vector of household characteristics (household wealth, access to water and sanitation, source of fuel). This helped capture the variables impact on child health. Xl,j which is a vector of biological and child endowment factors (birth order, birth size, gender and birth spacing). This helped capture the childs health endowment and its impact on mortality. Xm,j which is a vector of health services variables (place of delivery and tetanus injection). This helped capture the impact of health intervention in reducing mortality risk ej is the error term.

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The study estimated the following model; Lj = 0 + iXi,j + kXk,j + Xl,jl + mXm,j + ej.(3) Where Li is the dependent variable based on the probability of a child dying before the first birthday. It took only two values; 1 if the child was reported alive and 0 if the child was reported dead. The final model while including all variables was as given in equation (4) Lj = 0 + 1 MAGE + 2 MAGESQ + 3TNO + 4MRTS + 5MEDU1 + 6MAREL1 + 7 TORE1 + 8 HW1 + 9 ATW1 + 10 ATS1 + 11 BORD1 + 12 BSIZE11 + 13 G + 14 BSPA1 + 14 PLOD1 + 15 TTI1 + ei.. (4) Table 3.2: Variables Acronym Definition Acronym MAGE MAGESQ TNO MRTS MEDU MAREL TORE HW ATW ATS SCF BORD BSIZE G BSPA PLOD TTI Definition mothers age Mothers age squared Total number of children the mother has Marital status of the mother mothers highest level of education mothers religion households type of residence households wealth households access to water households access to sanitation households source of cooking fuel birth order of the infant birth size of the infant Gender of the infant birth spacing place of delivery of the infant tetanus toxoid injection for the infants mother

3.3 Estimation Technique

One problem the estimation encountered was on prevailing prices for health input goods given that DHS data did not collect information on prices. We followed, Kovsted et al. (2003) where

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we assumed identical prices for all the households and thus we estimated child health as a function of proximate biological inputs to child health (Y), child health input (I), household health knowledge (K), household wealth (W), and a childs health endowment .Similarly since health knowledge is assumed to be endogenous a bias could arise when parents are aware of a given health condition not known to the researcher. In this regard, mothers education was used to assess health knowledge (Medrano et al.2000). The estimation was done using the binary choice models since mortality rate is a discrete variable. Thus the dependant variable took only two values; 1 if the child was reported dead and 0 if the child was reported alive. The objective was to find the probability of the child dying or not dying. Three approaches could have been used; the linear probability model (LPM), the logistic regression model (logit) and the probit model (Gujarati, 2007). The LPM is the simplest to use but has some serious limitations. The error term violates the assumption of normality, the model suffers from heteroskedasticity and more seriously, there is always the possibility of the estimated probability lying outside the 0-1 bounds (Gujarati, 2007). Other limitations are limited usefulness of R2 and marginal effects are constant. Furthermore, the LPM is logically not a very attractive model even if the above limitations are solved in that it assumes that the conditional probabilities increase linearly with the values of the explanatory variables. A probability model that has an S-shaped feature of the cumulative distribution function is preferred. In practice the logistic and the normal cumulative distribution functions are chosen, giving rise to the logit and the probit models respectively. The study presented estimates using the logit model although the study estimated both logit and probit models with no significant differences in coefficients. Logit model is often used in literature (see Sewanyana and Younger, 2005; Da vanzo, 2004 and Elmahdi, 2008). This was noted to be as a result of the ease in interpreting results for logit model in terms of marginal effects which is impossible with probit model.

3.4 Variable Definitions

This section defines the variables which were analyzed in the study.

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Table3.3: Variable Definitions and Apriori expectation Variables Maternal characteristics Mothers age (MAGE) Very young and very old women are expected to increase child mortality risk. (Pandeyet al. 1998) Mothers highest education; None-(0) Primary -(1) Secondary -(2) Higher -(3) level of Higher education is expected to improve child health and survival,( Alves and Belluzzo, 2005) Definitions Apriori expectation

Mothers education (MEDU)

Type of residence (TORE)

Urban (1), Rural (0)

Rural residents are expected to have high child mortality risks than urban residents, (KabuboMariara et al., 2012) Religion impacts knowledge which is expected to improve health. (Pandey, et al., 1998)

Mothers Religion(MAREL)

Has Religion (1), No religion (0)

Total number of children (TNO) Marital status of the mother Married (1) (MRTS) Not married(0) Children Characteristics Gender (G) Male (1), Female (0) Boys are expected to have high mortality risks than girls, (Claeson et al.,2000)

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Birth Order (BORD)

The birth order of the child in First order and above 3 the family; birth order are expected to have negative impacts on First order -(1) mortality, (Da vanzo et al. 2-3 birth order-(0) 2004) Above 3 birth order -(2) Less than 24 months (1) More than 24 months (0) Better spacing is expected to have positive impacts on mortality, (Da vanzo et al. 2004) Small size and very large infants are expected to have high mortality risks, (Elmahdi, 2008)

Birth spacing (BSPA)

Birth size (BSIZE)

small/ very small -(1) average size-(0) Large/ very large -(2)

Household characteristics Households wealth (HW) Poor -(1) Middle -(0) Rich -(2) Household wealth is expected to impact child health positively, (Pandey, et.al., 1998)

Source of cooking fuel (SCF)

Electricity-(1) LPG-(2) Kerosene (3) wood -(4) coal/charcoal -(5) dung -(6) grass- (7)

Availability of clean cooking fuel free from air pollution is expected to improve child health, (Mutunga, 2004)

Access to sanitation (ATS)

No facility-(0) Flush toilet-(1) Ventilated improved pit (VIP) (2)

Clean human waste disposal facilities are expected to improve health, (Mutunga, 2004)

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Pit Toilet-(3) Other-(4) Access to water (ATW) Piped water -(1) public tap -(2) open well -(3) Rainwater -(4) Other -(5) River/Natural reserves- (6) Bottled water- (7) Health service variables Place of delivery (PLOD) Hospital (1) (0) Otherwise Availability of basic health amenities improves health, (Mosley and Chen, 1984) Injection with tetanus toxoid for pregnant mothers improves child health and survival, (Ssewanyana and Younger, 2005) Availability of clean drinking water is expected to improve child health and survival, (Mutunga, 2004)

Tetanus Toxoid injection (TTI)

Immunized (1) (0) Otherwise

3.5 Data Source and Analysis tool

The study used KDHS data for 2008/9 collected in Kenya. The data was downloaded from Measure DHS website after obtaining permission to download. The sample size for all interviewed women was 8,444 women aged between 15 to 49 years selected from 400 samples throughout Kenya. The survey utilized a two-stage sample based on the 1999 Population and Housing Census and was designed to produce separate estimates for key indicators for each province in Kenya.The study population for this analysis includes a sample of women who reported information on infants born one year before the study period. The observations at this level were 2425 representing mothers who had infants born for the period.

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CHAPTER FOUR: DATA ANALYSIS, RESULTS AND DISCUSSION

4.1 Introduction
This chapter presents the research findings for this study. Descriptive statistics are presented first then the findings on infant mortality rate in Kenya as well as the determining factors. The results are presented in tables followed by a discussion on the same. Logit results are presented and discussed.

4.2 Descriptive results

This study utilized data collected for women between the ages of 15-49years. Before the analysis was done various variables were regrouped to make the analysis more meaningful. For instance mothers age was grouped into seven categories to allow for analysis of very young and very old womens effect on infant mortality. Birth order was recoded to 2-3 birth order, first order and above 3 birth order following the study by Da Vanzo et al. (2004). Similarly as per the studys finding this study adopted their categorization on birth spacing into two; less than 24 months and more than 24 months. Other grouping was done on access to sanitation, place of delivery and access to water depending on the number of observations recorded and the appropriateness to the analysis. Table 4.4: Infant Mortality Rate as per 2208 KDHs data Number of infant dead Number of infants alive Total infant deaths per 1000 live births (IMR) 127 2,298 2425 55.27

As shown in table 4.4 infant mortality rate as per the KDHs data was 55.27 deaths per 1000 live births. This was as reported in the KDHs report. As earlier alluded in the introduction of this research Kenya still suffers from high infant mortality rate as compared to the MDGs target of 22 deaths per 1000 live births specific for Kenya. Our findings indicate that 5% of infants born are likely to die before celebrating their first birthday.

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Table 4.5: Sample statistic on the Independent variables used in the study Variable MAGE Value Names 14-19 years 20-24 years 25-29 years 30-34 years 35-39 years 40-44 years 45-49 years No education Primary Education Secondary Education Higher Education No religion Has religion Rural Urban Middle Poor Rich Piped Water Public Tap Open well Rainwater Other River/Natural reserves No facility Flush toilet VIP Pit toilet Other Female Male Home Hospital Not Immunized Immunized Frequency 260 774 616 445 231 80 19 478 1,395 428 124 86 2,339 1,812 613 380 1,117 928 404 304 947 35 53 682 589 246 348 1,221 21 1,145 1,280 1,313 1,107 330 1,951 Percent 10.72 31.92 25.4 18.35 9.53 3.3 0.78 20 58 18 5 3.55 96.45 74.72 25.28 15.67 46.06 38.27 16.66 12.54 39.05 1.44 2.19 28.12 24.29 10.14 14.35 50.35 0.87 47.22 52.78 54.14 45.65 14.35 84.86

MEDU

MAREL TORE HW

ATW

ATS

G PLOD TTI

The study utilized various variables as motivated by the Mosley and Chen (1984) framework. Table 4.5 gives a summary of the variables included in the model for infant mortality.

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From the findings in regard to maternal characteristics, majority of the women interviewed were between 20 and 24 years (32%) while only 0.78% of the interviewed women were between 45-49 years. In total all women interviewed were between 14 and 49 years. 58% had primary education, 18% had secondary education, 20% had no education while only 5% had higher education. In regard to religion, 96% of the respondents had some religion; Christianity or Muslim while 4% did not have any religion. 75% resided in rural areas with only 25% residing in urban areas. Households reported various characteristics which helped in analysis. Majority of the households (46%) were reported to be poor, 38% were reported to be rich while 16% were in the middle category. They reported their sources of water to be piped water (17%), public tap (13%), open well (39%), rainwater (2%), other sources (3%) and river/natural reserves (28%). Consequently 50% used pit toilets, 14% used ventilated improved toilets (vip), 10% used flush toilet, while 25% reported they did not have any facility. In regard to child characteristics, 53% of reported infants were male while 43% were female. In this study, place of delivery and tetanus injection were used as health facility related variables. Out of the respondent women 54% were reported to have delivered their children at home while 46% had delivered in a hospital either private or public. 84% had received tetanus injection while pregnant while only 16% did not receive the injection. Other important statistics are reported as below. Table 4.6: Mothers age in relation to Infant death age groups in years 15-19yrs 20-24yrs 25-29yrs 30-34yrs 35-39yrs 40-44yrs 45-49yrs Number of infants Number of infant infant deaths per 1000 live births alive dead (IMR) 246 14 57 741 33 45 585 31 53 418 27 65 218 13 60 73 7 100 17 2 117.6

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The mean age of interviewed women was 26years with the minimum age in child bearing reported as 15 years. According to Pandey et al. (1998) study very young and very old women had high risks of child and infant deaths. This study supports these findings as shown in table 4.3 where women aged15-19 years, 40-44 years and 45-49 years had high infant deaths of 57, 100 and 117 per 1000 live births respectively as compared to 45 and 53 infant deaths per 1000 live births among women aged 20-24years and 25-29 years respectively. Table 4.7: Mothers Education in relation to Infant death Mothers Education (MEDU) No education Primary Education Secondary Education Higher Education Number of infants Number of infant infant deaths per 1000 live alive dead births (IMR) 456 22 48.2 1,317 78 59.2 407 21 51.6 118 6 50.8

This study used mothers education to assess health knowledge. In contrast to literature findings women with no education had the lowest infant mortality rate (48%) followed by women with higher education (50.8%), women with secondary education (51.6%) and the highest infant mortality rate was reported among women with primary education.

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Table 4.8: Other independent variables in relation to infant mortality Variable MAREL TORE HW Value names No religion Has religion Rural Urban Middle Poor Rich Piped Water Public Tap Open well Rainwater Other River/Natura l reserves No facility Flush toilet VIP Pit toilet Other Female Male Home Hospital Average Small/Very small Large/Very large Number of infants alive 82 2216 1723 575 355 1067 876 377 287 907 34 48 645 566 230 332 1150 20 1089 1209 1255 1042 1216 380 684 Number of infant dead 4 123 89 38 25 50 52 27 17 40 1 5 37 23 16 16 71 1 56 71 58 65 50 30 42 infant deaths per 1000 live births (IMR) 48.8 55.5 51.7 66.1 70.4 46.9 59.4 71.6 59.2 44.1 29.4 104.2 57.4 40.6 69.6 48.2 61.7 50 51.4 58.7 46.2 62.4 41.1 78.9 61.4

ATW

ATS

G PLOD BSIZE

From table 4.8 infant mortality rate was reported to be high among women with religion (55%), those women who resided in urban areas (66%), women from household reported to be in the middle wealth quantile (70%), those who used piped water (71%), those who used flush toilets (69%) and those women who delivered in hospital. In regard to child characteristics infant mortality rate was reported to be high among male infants and infants born with small or very small birth size. 29

On the other hand infant mortality rate was reported to be low among women with no religion, women residing in rural areas, those who delivered at home, those from poor households and those from households that used rainwater. In regard to child characteristics infant mortality rate was reported to be low among female infants and large infant birth size.

4.3 Econometric analysis

The study estimated the relationship between infant mortality and various determinants; maternal characteristics, household characteristics, infants biological and health endowment as well as health service variables. The study examined how well the model fitted the data in order to obtain meaningful results. In terms of likelihood ratio statistics, all the models reported passed the goodness of fit. This implies that for every one of these models, there is at least one variable that is not equal to zero. This means that the dependent variable (infant mortality) is better explained by at least some of the independent variables than the constant alone. The study estimated the model using LPM and Logit. However only logit results are presented and discussed. In order to assess effect of health knowledge on infant mortality a second model was estimated while omitting mothers education so as to check the change on the significance, sign and effect of the remaining variables on infant mortality. This followed Medrano et al., (2000) study.

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Table 4.9: Results from Logit model for Infant mortality in Kenya. Model One Mage Magesq Tno Married Primary Education Secondary Education Higher Education Has religion Urban Poor Rich Public Tap Open well Rainwater Other River/Natural reserves Flush toilet Vip Pit toilet Small/Very small size Large/Very large size First order Above 3 birth order Male Less than 24 months Hospital Immunized _cons Coef. Std Error 0.168 0.129 0.004* 0.002 0.149 0.102 0.17 0.302 -0.22 0.358 -0.026 0.447 -0.11 0.604 0.134 0.639 0.201 0.334 0.598* 0.311 0.25 0.336 0.063 0.411 0.509 0.363 0.671 1.068 -0.832 0.546 0.015 0.384 -0.003 0.545 0.082 0.434 -0.219 0.341 0.651* 0.287 0.449* 0.242 0.536 0.386 -0.334 0.377 -0.081 0.214 -0.292 0.276 -0.237 0.253 0.135* 0.332 1.116 2.126 Model Two Mage Magesq Tno Married Coef. Std Error 0.176 0.127 0.004* 0.002 0.147 0.101 0.175 0.302

Has religion Urban Poor Rich Public Tap Open well Rainwater Other River/Natural reserves Flush toilet Vip Pit toilet Small/Very small size Large/Very large size First order Above 3 birth order Male Less than 24 months Hospital Immunized _cons

0.065 0.201 0.617* 0.266 0.054 0.489 0.697 -0.821 -0.002 -0.032 0.054 -0.266 0.641* 0.456* 0.548 -0.354 -0.081 -0.291 -0.229 0.155* 0.939 2265 0.0337

0.63 0.333 0.309 0.333 0.411 0.361 1.066 0.542 0.383 0.531 0.429 0.328 0.287 0.242 0.383 0.374 0.214 0.276 0.251 0.33 2.087

Number of Number of observations 2265 observations Prob > chi2 0.0636 Prob > chi2 * signifies parameter was statistically significant at the 10% level

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In model one, the independent variables used include, mothers age, mothers age squared, total number of children, marital status, religion, education, households type of residence, wealth, access to sanitation, sources of water, tetanus injection, place of delivery, birth size, birth order and birth spacing of the infant. The second model omits education. Table 4.10: Marginal effects from logit models

Marginal effects after Logit y = Pr(L) (predict) = 0.96416021 Variable MAGE MAGESQ TNO Married Primary Education Secondary Education Higher Education Has religion Urban Poor Rich Public Tap Open well Rainwater Other River/Natural reserves Flush toilet VIP Pit toilet Small/Very small size Large/Very large size First order Above 3 birth order Male Less than 24 months Hospital Immunized

Marginal effects after logit y = Pr(L) (predict) = .96401291 dy/dx Std Error 0.006 0.004 0.000* 0.000 0.005 0.004 0.006 0.012 -0.007 0.012 -0.001 0.016 -0.004 0.023 0.005 0.025 0.007 0.011 0.020* 0.011 0.008 0.011 0.002 0.014 0.017 0.011 0.017 0.020 -0.042 0.038 0.001 0.013 0.000 0.019 0.003 0.014 -0.008 0.012 0.028* 0.015 0.017* 0.010 0.016 0.010 -0.012 0.014 -0.003 0.007 -0.011 0.011 -0.008 0.009 0.004* 0.011 32 MAGE MAGESQ TNO Married Primary Education Secondary Education Higher Education Has religion Urban Poor Rich Public Tap Open well Rainwater Other River/Natural reserves Flush toilet VIP Pit toilet Small/Very small size Large/Very large size First order Above 3 birth order Male Less than 24 months Hospital Immunized dy/dx Std Error 0.006 0.004 0.000* 0.000 0.005 0.003 0.006 0.012

0.002 0.007 0.021* 0.009 0.002 0.016 0.018 -0.041 0.000 -0.001 0.002 -0.009 0.028* 0.017* 0.017 -0.013 -0.003 -0.011 -0.008 0.005*

0.023 0.011 0.011 0.011 0.014 0.012 0.020 0.038 0.013 0.019 0.014 0.011 0.015 0.010 0.010 0.014 0.007 0.011 0.009 0.010

* signifies parameter was statistically significant at the 10% level

4.4 Discussion of Results

Mothers age squared An increase in the age of the mother by one year increases the probability of infant mortality by 0.014 percent. The impact is the same when controlling for health knowledge using mothers education. These findings concur with earlier expectations on the effect of mothers age on infant mortality. It is expected that very young mothers may experience difficult pregnancies and deliveries because of their physical immaturity. They are also likely to have limited knowledge and confidence in caring for infants. Similarly, women who are very old may also experience age related problems during pregnancy and delivery. Similar results were also found by Madise et al (2003) in Zambia. Our findings support literature findings but contradicts Medrano et al. (2000) findings where educated mothers were expected to be more knowledgeable and thus to have low infant mortality. Poverty An increase in the proportion of women from households classified as poor relative to households classified as middle class by 1 percent would increase the probability of infant mortality by 2.05 percent. The impact of poverty increases to 2.12 percent when the model is controlled for health knowledge. This could imply that even though households could be poor, with knowledge they may come up with ideas to help them improve their living condition and thus reduce infant mortality. The findings support our apriori expectations where wealthy households are expected to have low infant mortality. Birth size The size of the baby at birth, either small or large, as reported by the mother is used in the study as a proxy for the childs birth weight since most of the children did not have birth weights. Infants reported born of small/very small size and those reported born of large/very large size had a 2.79 percent and 1.69 percent lower probability of infant deaths as compared to infants reported born of medium size. These findings contradict the expected results as infants born with small and large sizes were expected to have high mortality risk as discussed by Elhamadi (2003). Nevertheless other reserchers like Pandey, (1998) had reported similar results in India.

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Immunization Mothers immunized against tetanus while they were pregnant had a 0.45 percent reduced risk of having their children die before celebrating their first birthday. The impact was higher (0.51 percent) where health knowledge was not considered.

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CHAPTER FIVE: IMPLICATIONS 5.1 Introduction

SUMMARY,

CONCLUSIONS

AND

POLICY

This chapter outlines the summary on research findings, conclusion of the study as well as some policy recommendations with limitations of the study and suggestions for future research.

5.2 Research Summary

The major objective of this study was to establish empirically the determinants of infant mortality in Kenya. This was motivated by the fact that despite the reported decline in infant mortality the level was still high as per the MDG standard. Similarly infant mortality rate illustrates the lasting impacts of childhood health into adulthood and will thus impact economic performance of a country. The objectives of the study were to investigate whether demographic, socioeconomic, environmental and child health characteristics were important in explaining infant mortality in Kenya. This study was relevant as it would add to the existing knowledge in literature on infant mortality in Kenya. The study used individual household level data from the 2008 Kenya demographic and health survey. The logistic regression model was used due to the categorical nature of the dependent variable and he marginal effects were obtained using STATA statistical package. The results are given in chapter four and marginal effects were discussed.

5.3 Conclusion
From the analysis the study found out that mothers age was a key determinant to infant health. It did not matter whether the mother was knowledgeable or not as the impact was the same. As a woman ages their chances of having their children not celebrating their first birthday were higher by 0.014 percent. Therefore its important to encourage women to give birth at the middle ages where infant mortality rate risk was lower.

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The study found that households classified as poor had high risks of infant deaths as compared to the middle household category. Household wealth explains a lot in regard to households living standard in terms of education attained, ability to pay for hospital visits and use of better sanitation. Therefore there is need to improve households wealth so as to improve child survival. We found that education is very important in explaining infant survival. In this study education was used to assess health knowledge of mothers. Mothers with higher education were less likely to have their infant die before celebrating their first birthday as compared to mothers with no education. Similarly when education was included in the model the impact of the other variables on infant mortality was lower as compared to their impacts when education was omitted. Thus education is key to ensuring women are knowledgeable in terms of infants health during pregnancy and afterwards. This is important as it determines infants survival. Finally the study established lower infant mortality rate among women who had been immunized against tetanus while they were pregnant. Similarly large and small sized infants were found to have lower risk of infant death as compared to the middle infants. These findings contradict literature findings and could be as a result of the sample used. Majority of the interviewed women were from rural areas where belief on having a large sized infant signifies health could be rampant. Also the categorization was based on a womans judgment and thus the results would have been biased as size could be subjective.

5.4 Policy Implications based on key Results

The findings of the present study indicate that infant mortality risk is high as a woman ages. Therefore this study recommends that women be encouraged to bear children between 20 and 34 years of age and to have fewer children so as they get enough time to take care of the children. This can be done through making family planning services accessible to all especially in rural areas. Poverty has been found to be a great determinant of infant mortality in Kenya. The study found that majority of the respondent women were poor and lived in rural areas. There is need therefore to come up with programmes to assist women get financial empowerment. For instance the government can encourage commercial farming by promoting infrastructure development, opening up markets for various farm products by farmers, offering credit facilities at lower rate

36

to farmers, selling farm inputs at subsidized prices and also educating farmers on new farming techniques that will yield more output. Similarly women need be encouraged to join hands and mobilize resources for development. It was also noted from the results that the birth size of the infant is important in determining infant mortality in Kenya. The focus here could be directed on promoting healthy lifestyle for pregnant woman to take care of factors that could contribute to birth weight. This could be in the area of nutrition, exercise and avoidance of cigarette smoking. Similarly the results have shown that women with education are more knowledgeable and experience lower infant mortality than those with no primary education. With the inception of free primary education many children are acquiring primary education but are unable to progress to secondary due to factors like lack of fees despite the government subsidizing the fees in secondary school. In this regard the government could introduce a policy of providing free secondary education so that more females are motivated to go further with their studies which may in the long run result in reduction of infant mortality. Finally the study observed that women who had been immunized when pregnant had lower risk of encountering infant death. Thus its important to encourage women to attend ante natal clinic regularly for checkup and for general education.

5.5 Limitations of the study

This study aimed to inform policy regarding the determinants of infant mortality in Kenya. It was limited to the data already collected which was collected in the year 2008. This is the most recent available data and thus may not give up to date information. This was as a result of limited time to carry out the study and the amount of resources one may require to collect such data. Similarly the data had missing values which affected the quality of output. This was as a result of recall problem among interviewed women and biasness in reporting especially in the area of birth size. This could have been as a result of misplaced birth records, misreporting of deaths and omissions of birth reporting for the children who die very young.

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5.6 Suggestions for further study

In the light of the above shortcomings, a more comprehensive study would be required that would investigate the determinants of infant mortality by estimating two different models for neonatal, infant and child mortality capturing all the determinants of infant mortality including the ones outlined in this section . Recent collected data would also be appropriate. This would give to date information and would help capture the impacts of various variables in the children categories as what could affect infants would be different from what affects under five children. This will help inform policy effectively.

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REFERENCES
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APPENDIX
Figure 1.1: Infant Mortality and Under-five Mortality trend in Kenya (per 1000 live births)

Source: own construction based on word bank data (Source: data.worldbank.org/datacatalog/world-development-indicators)

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