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Child Survival in Urban BangladeshChild Survival in Urban Bangladesh::Are the urban migrants and poor Are the urban migrants and poor

disadvantaged?disadvantaged?

M. M. MazharulMazharul IslamIslamUniversity of Dhaka, BangladeshUniversity of Dhaka, Bangladesh

andandK M K M AbulAbul KalamKalam AzadAzad

Independent University, BangladeshIndependent University, Bangladesh

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BackgroundBackgroundBangladesh is predominantly a rural countryBangladesh is predominantly a rural country

In recent years it has been experiencing rapid In recent years it has been experiencing rapid urbanization urbanization

In 1974, only 9 percent of the population was In 1974, only 9 percent of the population was urbanized, which increased to 23 percent in 2001urbanized, which increased to 23 percent in 2001

Have one of the highest rate of growth of urban Have one of the highest rate of growth of urban population: 5.6 percentpopulation: 5.6 percent

Increased number of garment industries in urban areas Increased number of garment industries in urban areas add a new dimension not only in the economy of the add a new dimension not only in the economy of the country but also urbanization processcountry but also urbanization process

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RuralRural--Urban Migration in Bangladesh Urban Migration in Bangladesh

Globally, urban areas are growing, and the poor of Globally, urban areas are growing, and the poor of the world are increasingly urban.the world are increasingly urban.

A large number of rural poor migrates to urban A large number of rural poor migrates to urban areas in search of employment and income areas in search of employment and income

In Bangladesh, unplanned urbanization In Bangladesh, unplanned urbanization mushrooming slums and squattersmushrooming slums and squatters

This pattern of ruralThis pattern of rural--urban migration may have urban migration may have implication for health and survival of the implication for health and survival of the migrantmigrant’’s childrens children

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Objectives of the studyObjectives of the study

To analyze child survival status in urban To analyze child survival status in urban BangladeshBangladesh

To examine the implications of ruralTo examine the implications of rural--urban migration on child survival of the urban migration on child survival of the migrants and their economic development migrants and their economic development

To identify the determinants of child To identify the determinants of child survival in urban Bangladeshsurvival in urban Bangladesh

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Data and MethodData and Method

Data come from the 1999Data come from the 1999--2000 BDHS 2000 BDHS

Covered nationally representative sample of Covered nationally representative sample of 10,544 ever10,544 ever--married women of age 10married women of age 10--4949

2400 or 23% were rural to urban migrants 2400 or 23% were rural to urban migrants

BDHS Collected information on childhood BDHS Collected information on childhood residence, current place of residence, no. of years residence, current place of residence, no. of years spent in the current place and types of residence spent in the current place and types of residence prior to the most recent migration prior to the most recent migration

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Data and Method (cont..)Data and Method (cont..)

A woman who has reported her childhood and pervious A woman who has reported her childhood and pervious residences as rural and currently living in urban residences as rural and currently living in urban residence, is classified as rural to urban migrant. residence, is classified as rural to urban migrant.

Estimates of childhood mortality (i.e. probability of Estimates of childhood mortality (i.e. probability of death) are obtained by using conventional lifedeath) are obtained by using conventional life--table table approachapproach

The analysis is restricted to children born in last five The analysis is restricted to children born in last five yearsyears

Proportional hazard model is used to estimate the Proportional hazard model is used to estimate the relative risk of childhood mortalityrelative risk of childhood mortality

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Trends in Infant and childhood Trends in Infant and childhood mortality: 1989mortality: 1989--20032003

87

50

133

82

37

116

66

30

94

65

24

88

Infant Mortality Child Mortality Underfive Mortality

1989-1993 1992-1996 1995-1999 1999-2003

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Levels and Trends in U5 mortalityLevels and Trends in U5 mortality

020406080

100120140160180

1993/94 1996/97 1999/00 2003/04

Urban Rural

U5 mortality rate U5 mortality rate declined by 20% in urban declined by 20% in urban area, and 36% in rural area, and 36% in rural areaarea

Rural/urban differential Rural/urban differential in childhood in childhood

mortality diminishing, mortality diminishing, Why?Why?

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IMR by migration status: IMR by migration status: Are the migrants disadvantaged?Are the migrants disadvantaged?

72.2

86.1

81.7

50.6

75.6

0 20 40 60 80 100

R-U migrnat (10+yrs.)

R-U migrant (<10yrs.)

R-U migrant

Urban native

Rural Native

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UnderUnder--five mortality before and after five mortality before and after migrationmigration

116.9

98.5

Before migration After migration

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ANC Visit to doctor by Migration ANC Visit to doctor by Migration status status

43.9

39.4

42.5

61.7

16.7

0 10 20 30 40 50 60 70

R-U migrnat(10+yrs.)

R-U migrant(<10yrs.)

R-U migrant

Urban native

Rural Native

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Delivery in health facility by Delivery in health facility by migration statusmigration status

16.3

20.3

19.1

33.2

4

0 5 10 15 20 25 30 35

R-U migrnat (10+yrs.)

R-U migrant (<10yrs.)

R-U migrant

Urban native

Rural Native

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Coverage of Measles Vaccine by Coverage of Measles Vaccine by migration statusmigration status

78.2

70.7

76.4

86.7

67.5

0 20 40 60 80 100

R-U migrnat (10+yrs.)

R-U migrant (<10yrs.)

R-U migrant

Urban native

Rural Native

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Lack of Basic HH amenities by Lack of Basic HH amenities by migration statusmigration status

23.2

16.8

19.7

15.6

76.6

0 20 40 60 80 100

R-U migrnat (10+yrs.)

R-U migrant (<10yrs.)

R-U migrant

Urban native

Rural Native

Basic amenities include Electricity, piped drinking water or flush toilet etc.

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Ownership of no major consumer durables by Ownership of no major consumer durables by migration statusmigration status

20.9

17.8

19.3

13.2

39.1

0 10 20 30 40 50

R-U migration (10+ yrs.)

R-U Migration (<10 yrs.)

R-U migration

Urban Native

Rural Ntive

Consumer durables include: Radio, TV, watch, wardrobe etc.

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IMR among Poor and NonIMR among Poor and Non--poor by migration statuspoor by migration status

108.5

90.5

102.1

85.7

68.8

60.6

42.2

55.8

42.9

47.8

R-U migrnat (10+yrs.)

R-U migrant (<10yrs.)

R-U migrant

Urban native

Rural Native

Poor Non-poor

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U5 mortality by wealth quintile and U5 mortality by wealth quintile and Migration StatusMigration Status

102.1

78.3 73.566.3

120.2

137.8

96.9105.4

47.6

128.8

147.7

129119.9

62.8

119.3

0

20

40

60

80

100

120

140

160

Poorest Q2 Q3 Q4 RichestRural Urban R-U migrant

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Unadjusted Relative Risk of U5 mortality Unadjusted Relative Risk of U5 mortality (ref. = urban native)(ref. = urban native)

87%

122%

27%

0%

20%

40%

60%

80%

100%

120%

140%

Rural Native R-U migrant (<10yrs.) R-U migrant (10+yrs.)

77%

3%0%

10%20%30%40%50%60%70%80%90%

R-U migrant(<10yrs.)

R-U migrant(10+yrs.)

Total sample Urban sample

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Adjusted Relative Risk of U5 mortality among Adjusted Relative Risk of U5 mortality among children born in urban areachildren born in urban area

68%

-40% -36%

25%

114%

48%

-21%-3%

-9%

18%

R-U m

igrant <10

yrs.R-U

migrant 1

0+yrs.

Male ch

ildSec

ondary+

Parity

HH head

Work st

atus

Poorest

Age at b

irth <2

0 mWhite

colla

r job

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Relative risk of U5 mortality

Covariates Covariates RRRRMigration statusMigration status

Urban native (ref.)Urban native (ref.)RR--U migrants (<10yrs.) U migrants (<10yrs.) RR--U migrants (10+yrs.)U migrants (10+yrs.)

1.001.001.68***1.68***0.91**0.91**

Sex of childSex of childMaleMaleFemale (ref.)Female (ref.)

1.18**1.18**1.001.00

EducationEducationNo education (ref.)No education (ref.)PrimaryPrimarySecondary+Secondary+

1.001.001.011.010.84***0.84***

ParityParity 0.91**0.91**HH headHH head

Father (ref.)Father (ref.)MotherMotherOtherOther

1.001.000.64**0.64**1.11**1.11**

MotherMother’’s work statuss work statusYesYesNo (ref.)No (ref.)

1.25**1.25**1.001.00

HH economic statusHH economic statusPoorestPoorestQ2Q2Q3Q3Q4Q4Richest Richest

2.14***2.14***1.57***1.57***1.45**1.45**1.32**1.32**1.001.00

FatherFather’’s Professions ProfessionWhite collar job White collar job Others (ref.) Others (ref.)

0.790.791.001.00

MotherMother’’s age at child Births age at child Birth<20<202020--35 (ref.)35 (ref.)36+ 36+

1.48**1.48**1.001.001.13**1.13**

Note: * p< 0.05, ** p< 0.01, *** p< 0.001

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Conclusion Conclusion This study documents a sharp differentials in childhood This study documents a sharp differentials in childhood mortality between migrants and nonmortality between migrants and non--migrants within urban areasmigrants within urban areas

Urban migrants have significantly higher childhood mortality Urban migrants have significantly higher childhood mortality than urban natives but lower than rural nativesthan urban natives but lower than rural natives

RR--U migration promote child survivalU migration promote child survival

Mortality before age five is 1.6 times higher among children borMortality before age five is 1.6 times higher among children born n to urban migrants compared to the children born to lifelong to urban migrants compared to the children born to lifelong urban natives urban natives

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Conclusion Conclusion RR--U migrants are less likely to receive maternal and child health U migrants are less likely to receive maternal and child health care servicescare services

Poor/nonPoor/non--poor differential in child survival is higher in urban poor differential in child survival is higher in urban area than in rural areaarea than in rural area

Child survival status is worse among RChild survival status is worse among R--U migrant poor than U migrant poor than average urban pooraverage urban poor

Housing condition, access to safe drinking water and hygienic Housing condition, access to safe drinking water and hygienic toilet appeared as the most critical determinants of child survitoilet appeared as the most critical determinants of child survivalval

The study underscores the importance of motherThe study underscores the importance of mother’’s education s education beyond primary to improve the child survivalbeyond primary to improve the child survival

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ConclusionConclusion

The underlying efforts to improve child health in urban The underlying efforts to improve child health in urban Bangladesh, thus, is that of urban poor and the urban migrants, Bangladesh, thus, is that of urban poor and the urban migrants, who are growing rapidlywho are growing rapidly

The study results highlight the need to target migrant groups anThe study results highlight the need to target migrant groups and d urban poor within urban areas in the provision of health care urban poor within urban areas in the provision of health care servicesservices

Further research is needed to understand the health care needs Further research is needed to understand the health care needs of migrants in urban areas in order to develop the appropriate of migrants in urban areas in order to develop the appropriate health policy and planninghealth policy and planning