Length of maternal schooling and children's risk of malaria infection: evidence from a natural experiment in Uganda.

Introduction: An estimated 216 million cases of malaria occurred worldwide every year. Cross-sectional studies have reported negative association between maternal education and child malaria risks; however, no randomised trial or quasi-experimental study using a natural experiment has confirmed a causal relationship between these two factors. I used the free primary education reform in Uganda to assess the causal effects of maternal schooling on children's risk of malaria infection. Methods: Malaria biomarkers of children aged <5 years were collected from the 2009 and 2014 Uganda Malaria Indicator Surveys (n=5316). In 1997, the government eliminated tuition requirements in primary schools, which increased the educational attainment of the affected cohorts. Using exposure to the reform as an instrumental variable, I used a two-stage least squares approach to estimate the causal effects of maternal year of education on the probability that a child would contract malaria at the time of the survey. I also evaluated the cost-effectiveness of primary schooling as a malaria control intervention. Results: One extra year of maternal education reduced children's risk of malaria infection by 7.5 percentage points (p=0.057) from baseline (34.9%). The length of maternal education was also positively associated with insecticide-treated bednet usage by their children. The results were robust to a variety of sensitivity tests. Primary schooling for women was a cost-effective intervention to reduce children's malaria infection. Conclusion: Improving access to primary education could be a cost-effective measure to reduce malaria prevalence among children of educated mothers aged <5 years in malaria-endemic countries.