Life Course Approach to Child Survival

India has the greatest maternal and child health burden in the world, having more stunted and wasted children, neonatal deaths, and deaths of children under age five than any other nation (Paul et al. 2011; UNICEF 2013; 2018; Hug, Sharrow, and You 2017). Progress has been made in reducing these disparities in the past few decades, but it has not been enough to meet national or international goals. Although India has a long history of gender, caste and class-based inequalities, research considering the connections between these inequalities and childhood health and survival is lacking. The purpose of this dissertation is to examine whether under-five mortality in India reflects the physical embodiment and intergenerational transmission of social and contextual inequality. This study is guided by four specific research questions about neonatal mortality risk and survival through the fifth birthday, in recognition of the different cause-structures of mortality at these two stages of the life course: Question 1) Do elements of the maternal life course—family background, educational attainment, degree of personal agency—influence neonatal mortality risk? Question 2) Do maternal health status and health behaviors prior to and during gestation mediate the association between mothers’ life experiences and their neonates’ mortality risk? Question 3) Do state-level characteristics, including health system quality and degree of socioeconomic development, influence child survival and, if so, do they operate through proximate or intermediate factors? Question 4) Are household characteristics and environmental exposures associated with childhood survival, net of maternal characteristics, and are these relationships conditional on birth size? All analyses were conducted using the India National Family Health Survey (NFHS-4), which provided nationally representative data collected in 2015-2016. Questions 1 and 2 address the significance of the mother’s life course for her child’s survival during the first month of life using discrete time hazard models and mediation analyses. I examined the extent to which key elements of the mother’s earlier life experience, such as her family background, educational attainment, and her degree of agency, impact her newborn’s survival chance, and if these earlier life experiences predict her health and health behaviors around pregnancy. Mother’s education is significantly predictive of her physical health and prenatal care use in adulthood, and lowers her newborn’s mortality risk through these two proximate determinants. Greater decision-making power is also associated with more prenatal care visits, which ultimately lower her child’s hazard of death, net of all other factors. Questions 3 and 4 investigate the broader avenues through which inequality influences child health. I examined how contextual effects at the state-level are mediated or moderated by individual-level factors to impact the chance of under-five survival using discrete time hazard and interaction models. Greater educational attainment of women at the state level translates into lower odds of death for children, net of other structural measures. This contextual effect exerts its influence through household and individual-level measures, as it is no longer significant once markers of parental socioeconomic status are considered. For under-five mortality, the importance of the parent’s cultural capital is apparent. Unlike the neonatal period, father’s education retains a significant protective effect that does not appear to be mediated by other measures of socioeconomic status or birth conditions. While specific dimensions of household quality are not significantly related to child mortality on their own, net of other state and household factors, the protective effect of having access to a flush toilet is conditional on birth size. Only children not considered small at birth appear to reap a survival advantage from modern plumbing systems, which help to shield them from pathogens linked to diarrheal and other infectious diseases. For children with small birth sizes, higher-quality toilet facilities do not seem to raise or lower their already-higher odds of mortality. In total, this dissertation paints a holistic portrait of how structural and cultural barriers culminate in maternal and child health outcomes on the individual level. The findings provide policy makers and public health scholars with new insights on the risk factors of various stages of child mortality using current, nationally representative data. Furthermore, employing the life course framework provides a fresh perspective for analyzing the determinants of child survival in India, one that gives proper attention to the social and environmental experiences of the children and adults to whom they are linked.