From the *Harvard University Graduate School of Education, Cambridge, MA; †Department of Human Development, University Maryland, College Park, MD.
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It is often asserted in international health policy discussions that a woman's school attainment protects her children's health and survival chances, particularly in the less-developed countries (LDCs) of Asia, Africa, Latin America, and the Pacific, however questions concerning the processes involved remain unsettled. This article examines what we know about maternal schooling and child survival, proposes the acquisition of literacy as a pathway of influence, and reviews evidence concerning how literacy skills acquired in school affect maternal health behavior critical to child survival.The history of child survival in the LDCs during the second half of the 20th century is a dramatic one that is still being analyzed and interpreted.1 The average under-5 mortality rate of the LDCs decreased from 222 (per 1000 live births) in 1960 to 90 in 1999; the infant mortality rate alone dropped from 141 to 63. Table 1 shows the magnitude and scope, also the variability, of this “child survival revolution,” which was largely due to control of the infectious diseases (diarrheal diseases, including typhoid and cholera; acute respiratory infections, including measles and pneumonia; and other infections such as neonatal tetanus and malaria)—that had maintained high infant and child mortality levels in previous generations.The LDCs were undergoing a massive socioeconomic transformation during the same period, with urbanization, economic growth, and the expansion of transportation networks, mass communications, and schools occurring on a large scale, although it was also variable across countries and regions. With so many concurrent changes going on and being tracked as never before by national censuses and surveys, and with the increasing availability of high-speed computers in the 1960s and 1970s, social scientists examined the relationships of these trends to each other. National infant mortality rates, for example, turned out to be correlated with almost all indicators of socioeconomic development, and a country's infant mortality is often considered even nowadays to be a sensitive index of development. By 1980, it had become clear that declining infant and child mortality rates were strongly associated with rising levels of household income and women's schooling, and that maternal school attainment was a predictor of reduced infant and child mortality in LDCs even when income and other socioeconomic factors were controlled.2,3,4 This finding, contradicting the earlier assumption that maternal schooling was simply a proxy for income and social status, set the stage for further investigations of maternal schooling effects on child survival.Evidence from an increasing number of countries indicated that women's schooling was necessary if not sufficient to achieve child mortality reduction—a prerequisite for mortality decline. This view drew empirical support from the World Fertility Survey5,6 and the subsequent Demographic and Health Surveys (DHS),7,8 which were carried out on a large scale across the developing world. The World Fertility Survey and the DHS confirmed the finding that maternal schooling was independently associated with infant and child mortality, and they permitted a more detailed understanding of the complex relationships involved. For example, most of the effect of women's schooling on their children's survival chances during infancy was eliminated when income was controlled, but the effect on postinfancy child mortality remained strong. Many analyses not only replicated the schooling-mortality relationships in different settings but also showed schooling to be related to maternal behavior, particularly healthcare utilization and home hygiene practices.