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. 2015 Feb 26;12(4):929–939. doi: 10.1111/mcn.12178

The role of maternal education in the 15‐year trajectory of malnutrition in children under 5 years of age in Bangladesh

Md Tanvir Hasan 1,✉, Ricardo J Soares Magalhaes 2,3, Gail M Williams 1, Abdullah A Mamun 1
PMCID: PMC6860139  PMID: 25720451

Abstract

Malnutrition in children under 5 years of age (U5s) is a serious public health problem in low‐ and middle‐income countries including Bangladesh. Improved maternal education can contribute effectively to reduce child malnutrition. We examined the long‐term impact of maternal education on the risk of malnutrition in U5s and quantified the level of education required for the mothers to reduce the risk. We used pooled data from five nationwide demographic and health surveys conducted in 1996–1997, 1999–2000, 2004, 2007 and 2011 in Bangladesh involving 28 941 U5s. A log‐binomial regression model was used to examine the association between maternal education (no education, primary, secondary or more) and malnutrition in children, measured by stunting, underweight and wasting controlling for survey time, maternal age, maternal body mass index, maternal working status, parity, paternal education and wealth quintile. An overall improvement in maternal educational attainment was observed between 1996 and 2011. The prevalence of malnutrition although decreasing was consistently high among children of mothers with lower education compared with those of mothers with higher education. In adjusted models incorporating time effects, children of mothers with secondary or higher education were at lower risk of childhood stunting [risk ratio (RR): 0.86, 95% confidence interval (CI): 0.81, 0.89], underweight (RR: 0.83, 95% CI: 0.78, 0.88) and wasting (RR: 0.82, 95% CI: 0.74, 0.91) compared with children of mothers with no education. We demonstrated the importance of promoting women's education at least up to the secondary level as a means to tackle malnutrition in Bangladesh.

Keywords: malnutrition, children under 5 years of age, maternal education, Bangladesh

Introduction

A recent report by UNICEF, World Health Organization (WHO) and The World Bank estimated that in 2011, globally, 165 million children under 5 years of age (U5s) were stunted, 101 million were underweight and 52 million were wasted (UNICEF, WHO, The World Bank 2012). The report further stated that the prevalence of underweight and wasting was highest in South Asia compared with other parts of the world and the prevalence of stunting was similar in South Asia and in sub‐Saharan Africa. In 2011, in Bangladesh, an estimated 6 million U5s were suffering from stunting, 5 million were suffering from underweight and 2 million were suffering from wasting (UNICEF 2013). Most countries in East Asia are well on track to achieve the Millennium Development Goal 1 of reducing prevalence of underweight by half, but by 2009 half of the countries in South Asia including Bangladesh had made insufficient or no progress in achieving this (UNICEF 2009).

The association between malnutrition and subsequent poor health and development is well documented in the literature. Malnutrition has been reported to be closely associated with poor cognitive and education performance in children (Grantham‐McGregor et al. 2007). Poor fetal growth or stunting in the first two years of life leads to shorter adult height, lower levels of attained schooling, reduced adult income and decreased offspring birthweight (Victora et al. 2008). Micronutrient malnutrition accompanied by metabolic adaptation in response to nutrition deficiencies in children can increase the risk of later obesity and related chronic diseases (Eckhardt 2006). Low birthweight has been reported to be associated with increased plasma glucose and insulin concentration, later type 2 diabetes and insulin resistance (Hales et al. 1991; Boyko 2000; Mi et al. 2000; Newsome et al. 2003; Bhargava et al. 2004), as well as higher blood pressure (Law & Shiell 1996; Huxley et al. 2000; Lawlor & Smith 2005) and higher risk of ischaemic heart diseases (Huxley et al. 2007). The long‐lasting health effects of childhood malnutrition suggest that it is critical to tackle its onset before critical stages of childhood development are attained.

Previous research has investigated the determinants of malnutrition among U5s. Maternal education has been found to be strongly associated with nutritional outcomes of children (Barrera 1990; Gupta et al. 1991; Lomperis 1991; Victoria et al. 1992; Kassouf & Senauer 1996). Maternal knowledge of the causes of malnutrition and other socioeconomic factors are stronger risk factors than health care availability or health care‐seeking attitudes (Saito et al. 1997). Maternal education is estimated to be responsible for almost 43% of the reduction in malnutrition in children that took place between 1970 and 1995 in developing countries (Smith & Haddad 2000).

Some researchers have differed on the interpretation of a direct effect of maternal education on nutritional outcomes of children. Using data from 22 demographic and health surveys (DHS) from different parts of the developing world, Desai & Alva (1998) concluded that maternal education acts as a proxy for the socioeconomic status of the family and geographic area of residence. Once those factors are controlled for, the effect of maternal education on nutritional outcome of children is greatly attenuated. Another study by Reed et al. (1996) concluded that the effect of maternal education on nutritional outcome of children depends on the socioeconomic position of the family. The effect is positive and significant for families in intermediate positions and weakly positive for families in the best economic positions. Although debate still continues about the direct effect of maternal education on nutritional outcomes in children, most studies have shown that the prevalence of malnutrition is high among children of mothers with no education compared with children of mothers with some education (Emina et al. 2009).

Recent data indicate that women's education is improving in Bangladesh. The adult female literacy rate increased from 25.8% in 1991 to 54.3% in 2011 (Government of the People's Republic of Bangladesh 2012). The net enrolment rate in primary level education for girls was close to 100% in 2012 (Government of the People's Republic of Bangladesh 2013). These notable improvements in education of the female population in the last two decades would be expected to positively contribute to reducing malnutrition in U5s in the country. Indeed, previous research conducted in Bangladesh has demonstrated a positive association between nutritional outcomes of children and maternal educational attainment (Rayhan & Khan 2006; Mohsena et al. 2010; Jesmin et al. 2011; Siddiqi et al. 2011). However, all these studies relied on a single cross‐sectional dataset conducted at a particular time point. It remains unclear whether improvement of maternal education over time has positively contributed to reducing malnutrition in U5s in Bangladesh. In this study, we aim to investigate the impact of maternal education on nutritional outcome of U5s and quantify the level of education required for the mothers to reduce the risk of malnutrition in children utilizing the five most recent (i.e. 1996–1997, 1999–2000, 2004, 2007 and 2011) nationwide cross‐sectional DHS data in Bangladesh.

Key messages.

  • We investigated the impact of maternal education on nutritional outcome of children under 5 years of age for the past 15 years (1996 to 2011) in Bangladesh.

  • We found that over the past 15 years children of mothers with secondary or higher level of education were at lower risk of childhood stunting, underweight and wasting compared with children of mothers with primary education or with no education.

  • Future policy to tackle malnutrition in Bangladesh may consider promotion of women's education at least up to the secondary level.

Methods

Data sources

We pooled five DHS data conducted in 1996–1997, 1999–2000, 2004, 2007 and 2011 in Bangladesh. The DHS are cross‐sectional nationally representative surveys generally carried out in less‐developed countries. The surveys use a standardized questionnaire to gather basic demographic and health data. Data obtained using a DHS are generally considered to be of very high quality because of careful questionnaire design, training and supervision of interviewers and quality control checks during data processing (Pullum 2008). In Bangladesh, the DHS are conducted under the authority of the National Institute of Population Research and Training (NIPORT) and implemented by Mitra and Associates with financial support from the United States Agency for International Development and technical assistance from ICF International (formerly ORC Macro, Macro International Inc. and Institute for Resource Development, Inc.) (NIPORT et al. 2013). The surveys use a two‐stage stratified sampling design with urban/rural stratification in each division of the country (NIPORT et al. 2009, 2013). At the first stage, primary sampling units (PSUs), also known as census enumeration areas, are selected from both urban and rural areas based on probability proportional to enumeration size. At the second stage, households are systematically selected from these PSUs. Reproductive aged women (aged 15–49 years) are interviewed to collect information on child health (vaccination, childhood illness and newborn care), child feeding practices, vitamin supplementation, anthropometry, anaemia, salt iodization among others (The DHS Program 2014).

Variable definitions

We considered three common indicators of child malnutrition: stunting, underweight and wasting as the outcomes for this study. The WHO child growth standard was used to categorize children as stunted, underweight or wasted (WHO Multicentre Growth Reference Study Group 2006). The main predictor was maternal education which was categorized as no education, primary education and secondary or higher education. The other covariates included as potential confounders in the models were paternal education, year of survey, maternal age, maternal body mass index (BMI), maternal working status, number of children ever born and wealth quintile. Paternal education was categorized as for maternal education. Year of survey was considered a categorical covariate with values 1996, 1999, 2004, 2007 and 2011. Maternal age was grouped into three categories: less than 20 years, 20–30 years and 31 years and more. Maternal BMI, calculated as weight in kilogram divided by height in metre squared, was categorized into three groups: underweight mothers (BMI < 18.5 kg m−2), normal‐weight mothers (BMI 18.5–24.9 kg m−2) and overweight mothers (BMI ≥ 25.0 kg m−2) (WHO 2000). In DHS, height and weight data of mothers are collected in kilograms and centimetres, respectively, by trained interviewers (Pullum 2008). We excluded information of BMI of mothers who were pregnant at the time of surveys. Maternal working status was classed into two categories: working mothers and non‐working mothers. Working mothers were those who engaged in any work at the time of the surveys. They could be self‐employed or employed by others. Their type of earnings could be cash, cash and kind, in cash only and not paid at all. Number of children ever born (parity) was grouped into three categories: one child, 2–3 children and 4 or more. Finally, wealth index was classed into quintiles: poorest, poor, middle, rich and richest. In DHS, the wealth index is constructed using data on household assets and utility services as well as information on whether there is a domestic servant in the household and whether the household owns agricultural land (Rutstein & Johnson 2004). The index is genetrated by applying a similar technique (principal component analysis) in all surveys.

Statistical analysis

We summarized socioeconomic characteristics of 28 941 U5s. A trend of the prevalence of stunting, underweight and wasting by maternal educational attainment for the period 1996 to 2011 was shown. A log‐binomial regression model was used to examine the association of maternal education with nutritional outcomes of U5s over time (1996 to 2011). Previous studies have recommended using a log‐binomial model or a Poisson regression model with robust error variance to estimate relative risk when outcomes are common, as opposed to logistic regression model (Barros & Hirakata 2003). In this study, outcomes (stunting, underweight and wasting) were common. Therefore, a log‐binomial regression model was considered as an appropriate choice. We used the difficult option in Stata to overcome the convergence problems in model estimation (Cummings 2009).

To examine whether maternal education was independently associated with child malnutrition, we developed three models for each of the dichotomous outcomes – stunting, underweight and wasting. Model 1 included maternal education and year of survey as covariates to examine the effect of maternal education and time on nutritional outcome of children. Model 2 extended model 1 by including potential confounders such as paternal education, maternal age, maternal BMI, maternal working status, number of children ever born and wealth quintile in addition to maternal education and year of survey. Model 3 included a two‐way interaction between maternal education and year of survey and all the confounders included in model 2. The purpose of model 3 was to check if the effect of maternal education on nutritional outcome of U5s was different across survey years. Risk ratios (RR) and corresponding 95% confidence interval (CI) were calculated and statistical significance was determined by examining the P‐value of the Wald test statistic. All analyses include sampling weights based on the DHS design and were conducted using Stata version 12 (Stata Corporation, College Station, TX, USA).

Results

Sample characteristics

Half of the 28 941 U5s were females and one‐fifth were aged less than 1 year (Table 1). The proportion of children living in urban areas steadily increased from 9.4% in 1996 to 22.1% in 2011. An improvement in maternal educational attainment was observed during the period 1996 to 2011. The proportion of mothers with secondary or higher education increased from 16.7% in 1996 to 49.3% in 2011. Meanwhile, the proportion of mothers with no education decreased from 55.7% in 1996 to 20.0% in 2011.

Table 1.

Selected background characteristics and prevalence of malnutrition among 28 941 children aged less than 5 years: Bangladesh demographic and health surveys 1996–1997, 1999–2000, 2004, 2007 and 2011

Characteristics 1996–1997 (n = 4706) 1999–2000 (n = 5351) 2004 (n = 5937) 2007 (n = 5300) 2011 (n = 7647)
% n % n % n % n % n Mean (%) Total
Gender of child
Female 50.3 2353 49.3 2639 49.3 2932 50.4 2628 49.2 3740 49.7 14 292
Male 49.7 2353 50.7 2712 50.7 3005 49.6 2672 50.8 3907 50.3 14 649
Age of child (in months)
<12 20.3 943 21.0 1109 19.5 1170 20.0 1049 19.5 1484 20.1 5 755
12–23 19.8 941 21.0 1129 19.7 1169 20.5 1095 18.8 1443 19.9 5 777
24–35 19.6 922 19.2 1036 20.0 1216 20.2 1073 18.5 1441 19.5 5 688
36–47 20.4 959 18.5 991 20.7 1216 19.4 1048 22.2 1679 20.2 5 893
48–59 20.0 941 20.3 1086 20.1 1166 19.9 1035 21.1 1600 20.3 5 828
Maternal education
No education 55.7 2572 46.4 2385 37.5 2118 26.8 1420 20.0 1449 37.3 9 944
Primary 27.6 1337 29.1 1559 31.3 1868 31.6 1659 30.7 2330 30.1 8 753
Secondary or higher 16.7 797 24.4 1407 31.2 1951 41.6 2219 49.3 3868 32.6 10 242
Maternal body mass index (BMI)
Underweight (BMI ≤18.5 kg m−2) 51.9 2233 45.4 2183 38.2 2084 32.4 1610 28.5 2053 38.1 10 163
Normal (18.5 ≤ BMI < 25 kg m−2) 45.5 1977 50.6 2552 56.4 3146 60.0 2941 60.0 4266 55.2 14 882
Overweight (BMI ≥25 kg m−2) 2.6 115 4.0 238 5.4 360 7.6 455 11.5 900 6.7 2068
Maternal working status
Not working 66.0 3126 82.5 4456 82.3 4915 73.3 4036 90.9 6918 79.0 23 451
Working 34.0 1578 17.5 895 17.8 1022 26.7 1263 9.1 729 21.0 5 487
Paternal education
No education 46.4 2131 43.3 2176 40.1 2243 35.1 1787 29.7 2141 38.9 10 478
Primary 26.5 1262 25.0 1296 27.4 1622 28.0 1474 29.1 2224 27.2 7 878
Secondary or higher 27.1 1273 31.7 1800 32.5 2069 36.9 2033 41.2 3276 33.9 10 451
Residence
Urban 9.4 636 16.4 1366 19.6 1771 21.0 1850 22.1 2342 17.7 7 965
Rural 90.6 4070 83.6 3985 80.4 4166 79.0 3450 77.9 5305 82.3 20 976
Division
Barisal 6.5 488 6.1 469 6.0 656 6.4 696 5.4 837 6.1 3 146
Chittagong 24.6 852 22.2 1166 22.1 1302 21.8 1093 22.7 1516 22.7 5 929
Dhaka 31.3 1302 31.3 1287 30.7 1294 31.8 1122 31.3 1272 31.3 6 277
Khulna 10.1 465 10.4 796 10.9 776 9.6 630 9.4 894 10.1 3 561
Rajshahi 21.3 1063 22.7 942 22.2 1129 22.0 856 12.6 916 20.1 4 906
Sylhet 6.3 536 7.3 691 8.2 780 8.4 903 7.7 1219 7.6 4 129
Rangpur 10.9 993 – 993
Household wealth quintile
Poorest 21.4 974 25.1 1247 25.2 1353 22.4 1050 23.6 1682 23.5 6 306
Poorer 23.1 1048 22.1 1106 20.6 1127 21.6 1089 20.4 1489 21.6 5 859
Middle 19.4 920 19.3 997 19.7 1112 19.4 996 19.4 1456 19.4 5 481
Richer 19.8 914 17.3 919 18.1 1080 18.9 991 19.1 1493 18.6 5 397
Richest 16.4 850 16.2 1082 16.5 1265 17.8 1174 17.5 1527 16.9 5 898
Prevalence of malnutrition
Stunting 60.0 2823 51.2 2698 50.5 2951 42.9 2210 41.2 3110 49.2 13 792
Underweight 52.2 2443 41.8 2203 42.4 2461 40.8 2109 36.2 2738 42.7 11 954
Wasting 20.6 958 12.3 656 14.6 844 17.4 898 15.5 1184 16.1 4 540
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Trend of maternal education and malnutrition in U5s

A decreasing trend in the prevalence of stunting, underweight and wasting was observed among U5s during 1996–2011 regardless of maternal educational attainment (Fig. 1). The prevalence of stunting decreased by 15 percentage points (from 66.0% in 1996 to 51.0% in 2011) among children of mothers with no education compared with 4.9 percentage points (from 38.5% in 1996 to 33.6% in 2011) among children of mothers with secondary or higher education. The prevalence of underweight decreased by 9.7 percentage points (58.5% in 1996 to 48.8% in 2011) among children of mothers with no education whereas it decreased by 7.0 percentage points (from 34.3% in 1996 to 27.3% in 2011) among children of mothers with secondary or higher education. The prevalence of wasting did not change much – from 22.8% in 1996 to 17.8% in 2011 among children of mothers with no education and from 17.9% in 1996 to 13.0% in 2011 among children of mothers with secondary or higher education. Overall, the gap in the prevalence of stunting, underweight and wasting by maternal educational attainment narrowed over time.

Figure 1.

figure

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Trends in stunting, underweight and wasting by educational attainments of mothers: Bangladesh demographic and health surveys 1996–1997, 1999–2000, 2004, 2007 and 2011.

Association between maternal education and malnutrition in U5s

Multivariate log‐binomial regression results examining the effect of maternal education on the risk of stunting in U5s are presented in Table 2. Model 1 shows that children of mothers with secondary and higher education were at low risk of childhood stunting (RR: 0.63, 95% CI: 0.61, 0.65) compared with children of mothers with no education. However, adjustment for potential confounders (maternal age, maternal BMI, maternal working status, parity, paternal education and wealth quintile) in model 2 reduced the effect size (RR: 0.86, 95% CI: 0.81, 0.89) suggesting that the maternal education effect seen in model 1 was partly confounded by these covariates. After including two‐way interaction between maternal education × year of survey in model 3, the protective effects of secondary education of mothers remains apparent for different surveys; however, there is a lack of evidence of significant risk differentials over time between children of mothers with secondary and higher education and children of mothers with no education (P‐value for interaction = 0.818).

Table 2.

Adjusted risk ratios (RRs) and corresponding 95% confidence intervals (CIs) for the association between maternal education and stunting in children aged less than 5 years, 1996 to 2011

Covariates Model 1 Model 2 Model 3
RR (95% CI) RR (95% CI) RR (95% CI)
Maternal education      
Primary (vs. No education) 0.91 (0.89 0.94) 0.99 (0.97 1.03) 1.01 (0.95 1.07)
Secondary (vs. No education) 0.63 (0.61 0.65) 0.86 (0.81 0.89) 0.81 (0.73 0.90)
Year of survey      
1999 (vs. 1996) 0.88 (0.85 0.92) 0.87 (0.84 0.91) 0.88 (0.84 0.92)
2004 (vs. 1996) 0.89 (0.85 0.94) 0.89 (0.85 0.94) 0.90 (0.85 0.95)
2007 (vs. 1996) 0.80 (0.76 0.84) 0.79 (0.75 0.83) 0.78 (0.72 0.84)
2011 (vs. 1996) 0.79 (0.75 0.83) 0.79 (0.75 0.83) 0.78 (0.73 0.84)
Maternal education × year of survey
Primary × 1999 0.97 (0.92 1.04)
Secondary × 1999 0.83 (0.76 0.92)
Primary × 2004 0.97 (0.91 1.04)
Secondary × 2004 0.85 (0.79 0.92)
Primary × 2007 1.04 (0.95 1.13)
Secondary × 2007 0.86 (0.77 0.95)
Primary × 2011 1.00 (0.91 1.08)
Secondary × 2011 0.88 (0.81 0.95)
P‐value for overall interaction effect 0.818
Open in a new tab

Model 1 is adjusted for maternal education and year of survey. Model 2 is adjusted for maternal education, year of survey, maternal age, maternal BMI, maternal working status, parity, paternal education and wealth quintile. Model 3 is adjusted for all covariates in model 2 plus the interaction between maternal education and year of survey.

Similarly, secondary or higher education has strong protective effects against underweight and wasting in U5s as shown in Tables 3 and 4. In adjusted models (model 2 in Tables 3 and 4), children of mothers with secondary or higher education had lower risks of being underweight (RR: 0.83, 95% CI: 0.78, 0.88) and wasted (RR: 0.82, 95% CI: 0.74, 0.91) compared with children of mothers with no education. The interaction effect between maternal education × year of survey in model 3 provided little evidence to conclude that the effect of maternal education in the risk of underweight and wasting in U5s have changed over time (P‐value for overall test of interaction for underweight, P = 0.095; P‐value for overall test of interaction for wasting, P = 0.128).

Table 3.

Adjusted risk ratios (RRs) and corresponding 95% confidence intervals (CIs) for the association between maternal education and underweight in children aged less than 5 years, 1996 to 2011

Covariates Model 1 Model 2  Model 3
RR (95% CI) RR (95% CI) RR (95% CI)
Maternal education      
Primary (vs. No education) 0.88 (0.85 0.91) 0.97 (0.94 1.01) 0.97 (0.91 1.04)
Secondary (vs. No education) 0.60 (0.57 0.63) 0.83 (0.78 0.88) 0.85 (0.75 0.96)
Year of survey      
1999 (vs. 1996) 0.83 (0.79 0.88) 0.84 (0.80 0.88) 0.85 (0.80 0.91)
2004 (vs. 1996) 0.87 (0.82 0.92) 0.89 (0.84 0.94) 0.89 (0.83 0.95)
2007 (vs. 1996) 0.88 (0.83 0.93) 0.89 (0.85 0.94) 0.83 (0.77 0.90)
2011 (vs. 1996) 0.82 (0.77 0.87) 0.85 (0.80 0.90) 0.88 (0.81 0.96)
Maternal education × year of survey
Primary × 1999 0.95 (0.87 1.02)
Secondary × 1999 0.79 (0.71 0.89)
Primary × 2004 0.95 (0.88 1.03)
Secondary × 2004 0.85 (0.77 0.94)
Primary × 2007 1.07 (0.97 1.17)
Secondary × 2007 0.95 (0.85 1.06)
Primary × 2011 0.95 (0.86 1.03)
Secondary × 2011 0.75 (0.68 0.83)
P‐value for overall interaction effect 0.095
Open in a new tab

Model 1 is adjusted for maternal education and year of survey. Model 2 is adjusted for maternal education, year of survey, maternal age, maternal BMI, maternal working status, parity, paternal education and wealth quintile. Model 3 is adjusted for all covariates in model 2 plus the interaction between maternal education and year of survey.

Table 4.

Adjusted risk ratios (RRs) and corresponding 95% confidence intervals (CIs) for the association between maternal education and wasting in children aged less than 5 years, 1996 to 2011

Covariates Model 1 Model 2 Model 3
RR (95% CI) RR (95% CI ) RR (95% CI)
Maternal education      
Primary (vs. No education) 0.89 (0.82 0.95) 0.92 (0.85 1.00) 0.81 (0.69 0.95)
Secondary (vs. No education) 0.72 (0.67 0.78) 0.82 (0.74 0.91) 0.90 (0.74 1.10)
Year of survey      
1999 (vs. 1996) 0.62 (0.55 0.69) 0.65 (0.58 0.72) 0.67 (0.58 0.77)
2004 (vs. 1996) 0.74 (0.67 0.83) 0.79 (0.71 0.88) 0.77 (0.66 0.89)
2007 (vs. 1996) 0.92 (0.82 1.02) 0.98 (0.88 1.09) 0.90 (0.78 1.04)
2011 (vs. 1996) 0.84 (0.76 0.93) 0.90 (0.81 1.01) 0.88 (0.72 1.02)
Maternal education × year of survey
Primary × 1999 0.81 (0.67 1.00)
Secondary × 1999 0.73 (0.58 0.92)
Primary × 2004 0.92 (0.77 1.09)
Secondary × 2004 0.85 (0.70 1.03)
Primary × 2007 1.02 (0.86 1.21)
Secondary × 2007 0.86 (0.73 1.05)
Primary × 2011 1.02 (0.86 1.20)
Secondary × 2011 0.81 (0.68 0.97)
P‐value for overall interaction effect 0.128
Open in a new tab

Model 1 is adjusted for maternal education and year of survey. Model 2 is adjusted for maternal education, year of survey, maternal age, maternal BMI, maternal working status, parity, paternal education and wealth quintile. Model 3 is adjusted for all covariates in model 2 plus the interaction between maternal education and year of survey.

Discussion

In this study, we utilized a series of cross‐sectional nationally representative DHS data from Bangladesh to assess the contribution of maternal education to reduce childhood malnutrition for a period of 15 years (1996–2011). We observed that higher levels of maternal education are beneficial for better nutritional outcome of U5s. Importantly, our study demonstrates that children of mothers with secondary or higher education had a lower risk of childhood stunting, underweight and wasting compared with children of mothers with no education. This risk differential existed even after controlling for time, maternal age, maternal BMI, maternal working status, parity, paternal education and wealth quintile.

Previous research (Rayhan & Khan 2006; Das et al. 2008) found that primary education of mothers reduced the risk of childhood stunting, underweight and wasting in U5s in Bangladesh. However, our study extends existing knowledge in that we found that it is specifically secondary or higher education of mothers that contributes significantly to reducing the risk of malnutrition in U5s in Bangladesh, after adjusting for other factors related to socioeconomic position. This finding parallels that of Makoka (2013) who showed that a higher level of maternal education significantly reduced the odds of malnutrition in U5s in Malawi, Tanzania and Zimbabwe and that a lower level of education had no impact.

The prevalence of stunting, underweight and wasting were lower among children of mothers with secondary or higher education compared with children of mothers with primary education or with no education in most of the surveys. This pattern of prevalence was also reported in previous research (Rayhan & Khan 2006; Das et al. 2009; Siddiqi et al. 2011). While we could not explore the reason why the prevalence of malnutrition was low in children of educated mothers, studies have indicated that high levels of maternal education is associated with protective childcare behaviours such as vitamin A capsule receipt, complete childhood immunizations, better sanitation and use of iodized salt (Semba et al. 2008). Higher education also gives women a higher level of autonomy, greater decision‐making power in the family regarding health‐related matters and better use of modern health facilities which could lead to better health outcomes of children (Cleland & Van Ginneken 1988; Kishor 1995).

Our findings suggest that long‐term strategies for tackling malnutrition in U5s in Bangladesh must consider extending maternal education beyond primary education. Past studies have indicated various pathways such as socioeconomic status, health knowledge and attitudes towards health care, health and reproductive behaviours and female autonomy, through which maternal education could positively influence nutritional outcome of children (Frost et al. 2005; Emina et al. 2009). Since 1990, the Government of the People's Republic of Bangladesh has taken several initiatives to promote women education, such as free education up to higher secondary level, a female stipend programme, providing scholarships to meritorious students, providing financial support to purchase books and paying fees for public examinations (Government of the People's Republic of Bangladesh 2012). These initiatives may have positively contributed to achieving gender parity both at primary and secondary level education (Government of the People's Republic of Bangladesh 2013). However, until now female participation in secondary or higher level education is low compared with male (Government of the People's Republic of Bangladesh 2012). According to the most recent estimates, 15% of the men and 10% of the women completed secondary or higher education in 2011 (NIPORT et al. 2013). Despite the need to improve female participation in the secondary or higher level education, government interventions largely focused on meeting the Millennium Development Goal 2 of achieving universal primary education for all. While it is important to ensure primary education for all, our findings suggest that it is now time to start focusing on improving female participation in secondary or higher level education to reduce the risk of malnutrition in U5s in Bangladesh.

Several strengths and weaknesses of our study should be noted. The main strength is the use of a set of nationally representative DHS data to examine the long‐term impact of maternal education on the nutritional outcomes of U5s. DHS data have been considered for a long time as the gold standard for developing countries (Johnson et al. 2009). However, it should be noted that the DHSs are cross‐sectional, therefore limiting, our ability to describe causal relationships between factors in a regression model. An important strength of our analysis is the inclusion of important potential confounders during the modelling process. However, it is impractical to control for all influencing factors that are associated with nutritional outcome of children.

In conclusion, our findings suggest that secondary or higher education of mothers may have contributed effectively in reducing the risk of malnutrition in U5s in Bangladesh. Future policy to tackle malnutrition in U5s in Bangladesh may emphasize promotion of women's education at least through the secondary level.

Source of funding

This research received no specific grant from any funding agency, commercial or not‐for‐profit sectors. M.T.H is supported by an International Postgraduate Research Scholarship from the University of Queensland (#43054112).

Conflicts of interest

The authors declare that they have no conflicts of interest.

Contributor statement

MTH and AAM conceived the study. MTH performed data analysis and wrote the first draft. AAM and RJSM contributed to data interpretation and preparation of the manuscript. GMW edited and provided important intellectual feedback.

Acknowledgement

We thank MEASURE DHS for granting permission to use the Bangladesh DHS data.

Hasan, M. T. , Soares Magalhaes, R. J. , Williams, G. M. , and Mamun, A. A. (2016) The role of maternal education in the 15‐year trajectory of malnutrition in children under 5 years of age in Bangladesh. Maternal & Child Nutrition, 12: 929–939. doi: 10.1111/mcn.12178.

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