Globally, the under-five mortality rate declined by 59% between 1999 and 2018; from 93 deaths per 1000 live births to 39 per 1000 live births. ¹ However, this number needs to be improved as the United Nations’ Sustainable Development Goals (SDGs) target for 2030 is to reduce preventable under-five mortality to at least as low as 25 per 1000 live births. Moreover, achieving this goal becomes more challenging as most under-five mortality occurs in low and lower-middle-income countries, especially countries within Africa and South Asia, ^{1 , 2} where children’s health can be affected by several factors such as healthcare service quality, family wealth status, and social status, including mother's education level. ³

Many kinds of research had been conducted to identify the association between a mothers’ education level and their children’s health status. The evidence has shown that the mother’s education is an important determinant of the health of children. ⁴ It’s stated that even after accounting for household income, the number of siblings, health environments, and other socioeconomic variables, the mother’s literacy is still a major factor that influences children’s health status. ⁴ A study conducted in the Kashmir valley has shown an inverse relationship between women’s literacy rate and children’s mortality rate. This study found that women’s literacy has an immense contribution in declining the infant mortality rate (IMR) and maternal mortality rate (MMR) and thus can help in improving the health status of both women and children. ⁵ In sub-Saharan Africa, a study found that the decline in mortality rates of children under five years was much higher among the children born to mothers who have never received formal education. ⁶ In Indonesia, child vaccination rates were increased from 19% when mothers have no education, compared to 68% when mothers have at least secondary school education. ⁷ A study in India also showed that the female literacy rate is a good predictor of infant mortality rate in India. The study’s results showed that infant mortality rate was inversely related to women’s literacy rate, while men’s literacy was not. ⁸

Proper education is the first step in empowering women and young girls and providing women with the best possible chance for a prosperous and healthy life. ⁹ For women who go on to have families, education can also aid in household and family management. ¹⁰ Lastly, educating girls saves lives and builds stronger families, communities, and economies. In addition, an educated female population increases a country's productivity and promotes economic growth. ¹¹ According to an International Labor Organization report, educating girls has proven to be one of the most important ways of breaking poverty cycles and is likely to have significant impacts on access to formal jobs in the longer term. Moreover, it’s reported that some countries lose more than $1 billion a year by failing to educate girls to the same level as boys. Therefore, it’s believed that educating women will increase their opportunity to get a better job and receive a higher wage. Furthermore, this also may address gender imbalances especially in the labor force. ¹¹ By looking at the importance and benefits of women’s literacy in non-health sectors and regions, therefore, we conducted this study to identify the association between women’s literacy and children’s mortality rates among countries in Southeast Asia.

First, we developed Figures 1 and 2 to describe the children’s mortality rates and women’s literacy rates across the eleven countries in Southeast Asia during 2015 to 2019 period. Figure 1 showed that three countries with highest newborn mortality rates (NMR) was the Myanmar (2.36), Lao (2.31), and Timor-Leste (2.05). Meanwhile, the countries with the lowest NMR in the region were Singapore (0.1), Malaysia (0.44), and Brunei Darussalam (0.56). Similar with NMR, Lao (4.94), Myanmar (4.82), and Timor-Leste (4.74) were also the three countries with the highest UFMR in the Southeast Asia. Meanwhile, the countries with the lowest UFMR were Singapore (0.26), Malaysia (0.83), and Thailand (0.99). Then, as shown in Figure 2, we found that the Philippines (97.55), Brunei Darussalam (96.3), and Singapore (95.68) were the three countries with the highest rate of WL across countries in the Southeast Asia region. Meanwhile, the WL rates in this region were the lowest in Timor-Leste (64.21), Cambodia (75.03), Myanmar (79.06), and Lao (79.39).

Next, we developed Table 1 to describe the profile of the eleven study countries from 2015 to 2019. The weakest GE was found in Cambodia (-0.64), Lao (-0.55), Myanmar (-1.1), and Timor-Leste (-0.98). Meanwhile, the three countries that have the strongest GE were Singapore (2.22), Brunei Darussalam (1.17), and Malaysia (0.94). Next, none of the countries in this region were labeled as free countries, with six countries labeled as not-free (FS<40), and the remaining five countries labeled as partially free (FS=40-69). Lao was the country with the lowest (12.67) freedom score, while Timor-Leste was the highest (67.5). Moreover, among the eleven countries, HDI was very high in Singapore (0.93), Brunei Darussalam (0.84), and Malaysia (0.8), while Myanmar (0.57) and Cambodia (0.58) were the lowest. Then, in this region, the proportion of births attended by skilled health staff (BASHS) was the highest in Brunei Darussalam, Malaysia, Singapore, and Thailand (BASHS>99). Meanwhile, BASHS was the lowest in Timor-Leste (56.7), Myanmar (60.2), and Lao (64.4).

Lastly, Table 2 was developed to describe the results of the correlation analysis. From the five variables, the FS of a country was the only variable that was not significantly associated with children’s mortality rates in the countries studied. Meanwhile, out of the four variables that were significantly associated with children’s mortality rates, all of them were negatively associated. The association between women’s literacy and children’s mortality rates was (-0.73 and -0.76), while the association between other variables and children’s mortality rate was more than 90%.

Based on the results of our study, we found that no country in the ASEAN region has a children’s mortality rate above the global average during the 2015 to 2019 period. This finding is in line with the previous report which showed that children’s mortality rates above the global average were more commonly found in the African region ²² and not in Southeast Asia. Even Myanmar, which had the highest average newborn mortality rate, and Lao which had the highest average of under-five mortality rate in this region, had only 2.36 deaths and 4.82 per 1,000 live births from 2015 to 2019 respectively, compared to 17 deaths ²² and 38 deaths per 1000 live births ²³ globally. Furthermore, our study found that the three countries (Myanmar, Lao, and Timor-Leste) with the highest children’s mortality rate in this region were lower-middle-income countries. ²⁴ This finding is also coherent with the previous report that showed that the highest burden of under-five mortality is reported to be mostly found in low-income or lower-middle-income countries. ²³ In addition, previous evidences had shown that the income level of the country was extremely correlated with the children’ mortality rate. The poorest countries have the highest levels of child mortality, and the countries with the highest income have the lowest rates. ¹² The results of our study showed that countries like Singapore, Brunei, and Malaysia were among the countries with the lowest children mortality rates. Moreover, our study also found that the correlation between HDI and children’s mortality rates was very high (NMR: -0.93, UFMR: -0.90)

Next, our study found that out of eleven countries in the region, the majority (eight countries) had BASHS coverage above the global average (83%). ²⁵ Moreover, even the BASHS coverage in Brunei, Malaysia, Singapore, and Thailand reached more than 99%. On the other hand, our results showed that three other countries whose BASHS coverage was below the global average also had the highest children’s mortality rates in the region. Those three countries were Myanmar (60.2%), Lao (64.4%), and Timor-Leste (56.7%). This study results did not only show disparities in the Southeast Asia region but also confirm the United Nations International Children's Emergency Fund (UNICEF) report which states that although BASHS coverage continues to increase in 2020 globally, the coverage continues to be uneven with significant disparities between regions. ²⁵ In our study, the correlation between BASHS and children mortality rate were significantly high (NMR: -0.91, UFMR: -0.95).

Women who have literacy are believed to be able to use their knowledge and understanding to improve the welfare of their families. ¹⁴ Our study showed that the WL rates of seven countries in the Southeast Asia region from 2015 to 2019 were above the global average (83%) in 2019. Moreover, this study also found that the children’s mortality rates among these seven countries were much lower than the global average. ^{22 , 23} In addition, the previous study had been proven that better education of women might reduce mortality among children. ²⁶ However, our result showed the association between WL and children’s mortality rates among countries in Southeast Asia was only around 70% (NMR: -0.73, UFMR: -0.76). The implication of this finding can be seen from the low children’s mortality rates in Cambodia. While the WL there was the second lowest (75%) in the region after Timor-Leste (64.2%) and also below the global average, ^{23 , 22} the mortality rates among children in Cambodia were only slightly different from Indonesia and the Philippines which had much higher WL rates than Cambodia in the same period.

The governance of a country may have widespread effects on the health of its population. ²⁷ A previous study showed that the better the governance, the lower children’s mortality rates. In another study, it’s mentioned that the quality of governance is even more critical in determining a good outcome for both mother and child. ²⁸ This evidence was coherent to our finding that showed the strong negative association between governance and mortality rate among newborns (-0.92) and children under-five (-0.89). In our study results, Myanmar, Lao, Timor-Leste, and Cambodia were the four countries with the lowest government effectiveness, and also the countries with the highest children’s mortality rates in the Southeast Asia region during the 2015 to 2019 period.

Finally, our study showed a consistent negative association between all of our independent variables (WL, GE, FS, HDI, and BASHS) and both of our dependent variables (NMR and UFMR). However, we found that the relationship between the freedom status of a country (FS) and children’s mortality rates among countries in Southeast Asia from 2015 to 2019 was not statistically significant. Then, we also highlighted the association between WL and children’s mortality rates in this study which was only around 70%. This association is quite high but relatively low compared to other variables that we assessed in this study which correlate around 90% and above. Based on this study results, we assume that children’s mortality rates can be reduced and potentially achieve the SDGs target by 2030 with the improvement in multiple sectors such as governance, the economy, health care, and education, as well as by strengthening gender equality. Accelerated improvement in various sectors is urgently needed, considering that the latest SDG report mentions that many SDG indicators have experienced setbacks due to the impact of the COVID-19 pandemic. ²⁹

The results of our study found that there’s a significant association between women’s literacy and children’s mortality rates among countries in the Southeast Asia region during the 2015 to 2019 period. Moreover, the HDI, GE, and BASH also had a significant correlation with children’s mortality rates in the same period. However, among eleven countries in the Southeast Asia region from 2015 to 2019, there were 3 countries whose indicators were all below the global average, while there were also many countries whose all indicators were much better than the global average. In order to achieve the SDGs 2030 target which does not want to leave anyone behind, this kind of disparity must be addressed immediately. Therefore, we consider that it is necessary to re-strengthen the ASEAN as a binding organization for countries in the Southeast Asia region, by expanding the field of cooperation in ASEAN by including the health sector. The goal is that countries in the region will work together to achieve the SDGs targets by 2030.