ndom sampling. The first potential limitation of this study is the cross-sectional nature of the analysis. The study uses censored, synthetic cohort life table based on the birth history of children and reported characteristics of mothers and households. While some of the covariates used in our analysis, such as child's sex, antenatal care, mother's age at childbirth are fixed covariates, others, such as mother's education, household access to clean water and sanitation, and urban/rural residence could have changed during the last 5 years. In the analysis, all covariates are assumed to have been fixed during the study period. However, because the household characteristics and many of the other background characteristics are not likely to have changed much in the past 5 years and because the main finding in the analysis is relationship of multiple birth status and child survival, the cross-sectional effects estimated in these studies are good measures of child survival among multiple births.
Another limitation of this study worth mentioning is that measuring wealth is problematic. Many of the household wealth indices use assets that are more likely to be found in urban areas than in rural areas. Thus, most of the rural households will be in the lowest wealth category even if they have other indicators of wealth (e.g., livestock or farm machinery). The consequence of this misclassification would be to lower the mortality risks of rural households. Another limitation with household wealth indices derived from DHS is that they are based on current status data so that they might not capture the true level of household wealth during the infancy of children born several years before the survey. However, since these analyses are restricted to births within five years of the surveys, this bias will not be substantial.
In summary, we found that children born multiple births are more likely to die during the first year of life compare to children born singletons, independent of child's sex, birth order, pregnancy care and delivery care, maternal education and nutritional status, household access to clean water and sanitation, and other factors. We also found that the mother's education played a protective role against infant death. This evidence suggests that improving maternal education may be key to improving child survival in Nigeria. A well educated has a better chance of satisfying important factors that can improve infant survival: the quality of infant feeding, general care, household sanitation, and adequate use of preventive and curative health services.
The authors declare that they have no competing interests.
OAU: Major role in study conception, data extraction, analyses, and writing of the manuscript. MBU: Data extraction, statistical analyses of data and manuscript writing. IY: Data extraction, statistical analyses of data and manuscript writing. All authors have read and approved the final manuscript.
The pre-publication history for this paper can be accessed here:
Table 1. Sample distribution and infant mortality rate (IMR) among children born during 1999 – 2003 by household wealth status and other selected characteristics, Nigeria 2003*.
Click here for additional data file (1471-2393-8-41-S1.doc)
Additional file 2
Table 2. Unadjusted and adjusted hazard ratio estimates the risk of multiple-birth mortality before 12 months of age, controlling for several factors among children born during 1999 – 2003, Nigeria 2003‡.
Click here for additional data file (1471-2393-8-41-S2.doc)
The author thanks Babara Luke and Albrecht Jahn for critical review of an earlier version of this manuscript. The authors are grateful to Measure DHS for providing them with the 2003 Nigeria DHS data.
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