A causal model of high rates of child mortality.

The distribution of child mortality has often been misunderstood because of insufficient attention to its context. High rates of child mortality in developing countries have variously been attributed to child neglect, cultural traditions of child care, population pressure, low maternal educational levels, lack of medical care, and insufficient basic resources. The model proposed in this article organizes factors leading to high child mortality rates onto three tiers to contextualize the medical causes of death and the debate over traditions of child care. The proximate tier includes the immediate biomedical conditions that result in death, typically involving interactions of malnutrition and infection. The intermediate tier includes child care practices and other behavior that increase the exposure of children to causes of death on the proximate tier. The ultimate tier encompasses the broad social, economic, and cultural processes and structures that lead to the differential distribution of basic necessities, especially food, shelter, and sanitation. The ultimate tier thus forms the context of causes located on the other tiers. Research from rural Mexico, Central America, and Africa supports various parts of the model, particularly concerning traditional parental behavior, which has often been interpreted as child neglect but appears in many cases to result ultimately from economic scarcity. Links from tier to tier in the model especially warrant further attention from both researchers and policy makers.