Elsevier

Social Science & Medicine

Volume 38, Issue 2, January 1994, Pages 253-268
Social Science & Medicine

A causal model of high rates of child mortality

https://doi.org/10.1016/0277-9536(94)90395-6Get rights and content

Abstract

The distribution of child mortality has often been misunderstood because of insufficient attention to its context. High rates of child mortality in developing countries have variously been attributed to child neglect, cultural traditions of child care, population pressure, low maternal educational levels, lack of medical care, and insufficient basic resources. The model proposed in this article organizes factors leading to high child mortality rates onto three tiers to contextualize the medical causes of death and the debate over traditions of child care. The proximate tier includes the immediate biomedical conditions that result in death, typically involving interactions of malnutrition and infection. The intermediate tier includes child care practices and other behavior that increase the exposure of children to causes of death on the proximate tier. The ultimate tier encompasses the broad social, economic, and cultural processes and structures that lead to the differential distribution of basic necessities, especially food, shelter, and sanitation. The ultimate tier thus forms the context of causes located on the other tiers. Research from rural Mexico, Central America, and Africa supports various parts of the model, particularly concerning traditional parental behavior, which has often interpreted as child neglect but appears in many cases to result ultimately from economic scarcity. Links from tier to tier in the model especially warrant further attention from both researchers and policy makers.

References (97)

  • P. Ramalingaswami

    The child as a focus for health promotion in the developing world

    Soc. Sci. Med.

    (1986)
  • A. Antonovsky

    Social class, life expectancy and overall mortality

    Milbank meml Fund Q.

    (1967)
  • K. Davis et al.

    Health and the War on Poverty: A Ten-year Appraisal

    (1978)
  • E.D. Driver

    Differential Fertility in Central India

    (1963)
  • A.C. Laurell et al.

    El desarrollo urbano y los patrones de consumo de productos farmacéuticos: una encuesta en diferentes grupos sociales de México, D.F.

    Salud publ. Méx. 5

    (1977)
  • N.E. Waxler et al.

    Infant mortality in Sri Lankan households: a causal model

    Soc. Sci. Med.

    (1985)
  • J. Holian

    Infant mortality and health care in Mexican communities

    Soc. Sci. Med.

    (1989)
  • J. Balan et al.

    Men in a Developing Society: Social and Geographic Mobility in Monterrey, Mexico

    (1973)
  • B.L. Wolfe et al.

    Determinants of child mortality, health, and nutrition in a developing country

    J. Dev. Econ.

    (1982)
  • R. Lightbourne et al.

    The World Fertility Survey: Charting Global Childbearing

    Popul. Bull.

    (1982)
  • A.V. Millard

    Corn, cash and population genetics: family demography in rural Mexico

  • A.V. Millard et al.

    Breastfeeding in two Mexican villages: social and demographic perspectives

  • B.D. Miller

    Daughter neglect, women's work, and marriage: Pakistan and Bangladesh compared

    Med. Anthrop.

    (1984)
  • T. Wise

    The current food crisis in Latin America

    Latin Am. Perspec.

    (1987)
  • W.H. Mosley

    Will primary care reduce infant and child mortality? A critique of some current strategies, with special reference to Africa and Asia

  • W.H. Mosley et al.

    An analytical framework for the study of child survival in developing countries

    Popul. Dev. Rev.

    (1984)
  • A.V. Millird et al.

    Agricultural development and malnutrition: a causal model of child mortality

  • T.H. Hull et al.

    Prospects for rapid decline of mortality rates in Java: a study of the causes of death and the feasibility of policy interventions for mortality control

  • A. Aguirre

    Columbia: the Family in Candelaria

    Stud. Family Plann.

    (1966)
  • R. Martorell et al.

    Diarrheal disease and growth retardation in preschool Guatemalan children

    Am. J. phys. Anthrop.

    (1975)
  • J.D. Wray et al.

    Protein calorie malnutrition in Candelaria, Colombia—I. Prevalence, social and demographic causal factors

    J. trop. Pediatr.

    (1969)
  • F. Alba

    The Population of Mexico: Trends, Issues, and Policies

    (1982)
  • R.R. Puffer et al.

    Patterns of mortality in childhood

  • R.R. Puffer et al.

    Birthweight, maternal age, and birth order: three important determinants in infant mortality

    Pan. Am. Hlth Organ. Sci. Publication

    (1975)
  • R.R. Puffer et al.

    Results of the interAmerican investigations of mortality relating to reproduction

    Bull. Pan. Am. Hlth

    (1976)
  • S.P. Erlich

    Selected conditions in the Americas: a guide for health research policy

    Bull. Pan Am. Hlth Orgn

    (1983)
  • C.M. Cassidy

    Benign neglect and toddler malnutrition

    Bull. Pan Am. Hlth

    (1980)
    C.M. Cassidy

    Malnutrition as a culture-bound syndrome

    Culture, Med. Psychiat.

    (1982)
  • D.B. Jelliffe et al.

    Human Milk in the Modern World

    (1978)
  • S.C.M. Scrimshaw

    Infant mortality and behavior in the regulation of family size

    Population Development Rev.

    (1978)
  • M. Nations et al.

    Angels with wet wings won't fly: maternal sentiment in Brazil and the image of neglect

    Culture, Med. Psychiat.

    (1988)
  • N. Scheper-Hughes

    Maternal detachment and infant survival in a Brazilian shantytown—a critique of bonding theory

    Soc. Sci. Med.

    (1984)
  • N. Scheper-Hughes

    Culture, scarcity, and maternal thinking: mother love and child death in Northeast Brazil

    N. Scheper-Hughes

    The cultural politics of child survival

  • N. Scheper-Hughes

    Letter to the editor

    Culture, Med. Psychiat.

    (1988)
  • Howard M. T. Kwashiorkor—Culture-Bound Syndrome? Presented at the Annual Meeting, American Anthropological Association,...
  • L.M. Morgan

    The medicalization of anthropology: a critical perspective on the critical-clinical debate

    Soc. Sci. Med.

    (1990)
  • L.M. Morgan

    Dependency theory in the political economy of health

    Med. Anthrop. Q.

    (1987)
  • H.A. Baer

    The possibilities and dilemmas of building bridges between critical medical anthropology and clinical anthropology: a discussion

    Soc. Sci. Med.

    (1990)
  • H.A. Baer et al.

    Towards a critical medical anthropology

    Soc. Sci. Med.

    (1986)
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