The Global Effect of Maternal Education on Complete Childhood Vaccination: A Systematic Review and Meta-Analysis

There is an established correlation between maternal education and reduction in childhood mortality. One proposed link is that an increase in maternal education will lead to an increase in health care access and vaccine uptake. The purpose of this study was to quantify the association between increasing maternal education and vaccine coverage in children and to assess the variation in effect of maternal education by continent, setting, and over time.

Medline, Embase, and the Cochrane Library were electronically searched on June 29 2016 using a combination of keywords and MeSH terms describing maternal education and child vaccination uptake. Bibliographies were also hand searched. The search was restricted to English language and limited to those published between 1990 and 2016.

The online search yielded 3,430 papers, 37 of which were included in this study. The analysis showed increasing child vaccination uptake with increasing maternal education. Specifically, it showed that the odds of full childhood vaccination were 2.31 times (95% confidence interval (CI) 1.90-2.79) greater in children whose mothers had received secondary or higher education when compared to those whose mothers had no education or primary level education. Only 42.8% (95% CI 35.2-50.4) of children whose mothers had no education were fully vaccinated. This increases to 80.2% (95% CI 75.5-85.0) amongst children whose mothers had completed tertiary education. Although all but 4 studies showed a positive effect of being highly educated, the effect size varied greatly between papers, with an overall I-squared value of 95.0% (p<0.001), indicating a high level of heterogeneity.

A separate meta-analysis of 6 studies split mothers based upon whether they were literate or illiterate. It demonstrates that full vaccination of children was more likely in mothers that were literate compared to illiterate, with an odds ratio of 2.87 (95% CI 2.39-3.46). Subgroup analysis of continents showed the overall effect size is highest in Asia, where the odds of full childhood vaccination were 2.65 times (95% CI 2.08-3.37) greater if the mother was more educated. The higher odds ratio of maternal education on vaccination uptake in Asia and Africa may demonstrate that education plays a more important role in lower income countries. This could be due to societal development as areas with better education may also have improved healthcare access. While the effect is lower in Europe, it is still positive. This demonstrates the importance of maternal education even in the presence of good health care programmes.

Within the setting subgroup analysis, vaccination of children was most likely in highly educated women in rural areas, with an odds ratio 2.17 (95% CI 1.48-3.17).

This study does not answer the question of exactly how maternal education increases vaccine uptake, but previous studies (cited here) have theorised that maternal education, specifically literacy, enhances cognition and communication skills, which encourage healthier lifestyle choices, leading to lower childhood mortality.