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Background India has achieved impressive gains in child survival over the last two decades; however, it was not successful in attaining MDG 2015 goals. The study’s objective is to inquire how the survival status of the preceding child affects the survival of the next born child. Methods This is a retrospective analysis of data from the National Family Health Survey, 2015–16. Analysis was restricted to women with second or higher-order births because women with first-order births do not have a preceding child. Proportional hazards regression, also called the Cox regression model, has been used to carry out the analysis. Kaplan–Meier (K–M) survival curves were also generated, with a focus on preceding birth intervals. Results Results found that female children were more likely to experience infant mortality than their male counterparts. Children born after birth intervals of 36+ months were least likely to experience infant mortality. Mother’s education and household wealth are two strong predictors of child survival, while the place of residence and caste did not show any effect in the Cox proportional model. Infant and child deaths are highly clustered among those mothers whose earlier child is dead. Conclusion Maternal childbearing age is still low in India, and it poses a high risk of infant and child death. Education is a way out, and there is a need to focus on girl’s education. The government shall also focus on raising awareness of the importance of spacing between two successive births. There is also a need to create a better health infrastructure catering to the needs of rich and poor people alike.

Background Complete childhood vaccination remains poor in Sub-Saharan Africa, despite major improvement in childhood vaccination coverage worldwide. Globally, an estimated 2.5 million children die annually from vaccine-preventable diseases. While studies are being conducted in different East African countries, there is limited evidence of complete basic childhood vaccinations and associated factors in East Africa among children aged 12–23 months. Therefore, this study aimed to investigate complete basic childhood vaccinations and associated factors among children aged 12–23 months in East Africa. Methods Based on the Demographic and Health Surveys (DHSs) of 12 East African countries (Burundi, Ethiopia, Comoros, Uganda, Rwanda, Tanzania, Mozambique, Madagascar, Zimbabwe, Kenya, Zambia, and Malawi), secondary data analysis was performed. The study included a total weighted sample of 18,811 children aged 12–23 months. The basic childhood vaccination coverage was presented using a bar graph. Multilevel binary logistic regression analysis was fitted for identifying significantly associated factors because the DHS has a hierarchical nature. The Intra-class Correlation Coefficient (ICC), Median Odds Ratio (MOR), Proportional Change in Variance (PCV), and deviance (−2LLR) were used for checking model fitness, and for model comparison. Variable with p-value ≤0.2 in the bi-variable multilevel analysis were considered for the multivariable analysis. In the multivariable multilevel analysis, the Adjusted Odds Ratio (AOR) with 95% Confidence Interval (CI) were reported to declare the significance and strength of association with full vaccination. Results Complete basic childhood vaccination in East Africa was 69.21% (95% CI, 69.20, 69.21%). In the multivariable multilevel analysis; Mothers aged 25–34 years (AOR = 1.21, 95% CI: 1.10, 1.32), mothers aged 35 years and above (AOR = 1.50, 95% CI: 1.31, 1.71), maternal primary education (AOR = 1.26, 95% CI: 1.15, 1.38), maternal secondary education and above (AOR = 1.54, 95% CI: 1.36, 1.75), husband primary education (AOR = 1.25, 95% CI: 1.13, 1.39), husband secondary education and above (AOR = 1.24, 95% CI: 1.11, 1.40), media exposure (AOR = 1.23, 95% CI: 1.13, 1.33), birth interval of 24–48 months (AOR = 1.28, 95% CI: 1.15, 1.42), birth interval greater than 48 months (AOR = 1.35, 95% CI: 1.21, 1.50), having 1–3 ANC visit (AOR = 3.24, 95% CI: 2.78, 3.77), four and above ANC visit (AOR = 3.68, 95% CI: 3.17, 4.28), PNC visit (AOR = 1.34, 95% CI: 1.23, 1.47), health facility delivery (AOR = 1.48, 95% CI: 1.35, 1.62), large size at birth 1.09 (AOR = 1.09, 95% CI: 1.01, 1.19), being 4–6 births (AOR = 0.83, 95% CI: 0.75, 0.91), being above the sixth birth (AOR = 0.60, 95% CI: 0.52, 0.70), middle wealth index (AOR = 1.16, 95% CI: 1.06, 1.28), rich wealth index (AOR = 1.20, 95% CI: 1.09, 1.33), community poverty (AOR = 1.21, 95% CI: 1.11, 1.32) and country were significantly associated with complete childhood vaccination. Conclusions In East Africa, full basic childhood vaccine coverage remains a major public health concern with substantial differences across countries. Complete basic childhood vaccination was significantly associated with maternal age, maternal education, husband education, media exposure, preceding birth interval, number of ANC visits, PNC visits, place of delivery, child-size at birth, parity, wealth index, country, and community poverty. Public health interventions should therefore target children born to uneducated mothers and fathers, poor families, and those who have not used maternal health services to enhance full childhood vaccination to reduce the incidence of child mortality from vaccine-preventable diseases.

Background The incidence of maternal mortality remains unacceptably high in developing countries. Ethiopia has developed many strategies to reduce maternal and child mortality by encouraging institutional delivery services. However, only one-fourth of women gave birth at health facility, in the country. This, this study aimed to identify individual level factors and to assess the regional variation of institutional delivery utilization in Ethiopia. Methods Data were obtained from the 2016 Ethiopian demographic and health survey. In this study, a total of 7174 reproductive age women who had birth within five years were included. We fitted multilevel logistic regression model to identify significantly associated factors associated with institutional delivery. A mixture chi-square test was used to test random effects. Statistical significance was declared at p Result The level of institutional delivery was 38.9%. Women’s who had focused antenatal care (FANC) visit (AOR = 3.12, 95% CI: 2.73–3.56), multiple gestations (AOR = 2.06, 95% CI: 1.32–3.21, and being urban residence (AOR = 7.18, 95% CI: 5.10–10.12) were more likely to give birth at health facility compared to its counterpart. Compared to women’s without formal education, giving birth at health facility was more likely for women’s who had primary education level (AOR = 1.77, 95% CI: 1.49–2.10), secondary education level (AOR = 3.79, 95% CI: 2.72–5.30), and higher education level (AOR = 5.86, 95% CI: 3.25–10.58). Furthermore, women who reside in rich (AOR = 2.39, 95% CI: 1.86–3.06) and middle (AOR = 1.66, 95% CI: 1.36–2.03) household wealth index were more likely to deliver at health facility compared to women’s who reside poor household wealth index. Moreover, this study revealed that 34% of the total variation in the odds of women delivered at health institution accounted by regional level. Conclusion The level of institutional delivery in Ethiopia remains low. Context specific and tailored programs that includes educating women and improving access to ANC services has a potential to improve institutional delivery in Ethiopia.

Background To reduce the under-five mortality (U5M), fine-gained spatial assessment of the effects of health interventions is critical because national averages can obscure important sub-national disparities. In turn, sub-national estimates can guide control programmes for spatial targeting. The purpose of our study is to quantify associations of interventions with U5M rate at national and sub-national scales in Uganda and to identify interventions associated with the largest reductions in U5M rate at the sub-national scale. Methods Spatially explicit data on U5M, interventions and sociodemographic indicators were obtained from the 2011 Uganda Demographic and Health Survey (DHS). Climatic data were extracted from remote sensing sources. Bayesian geostatistical Weibull proportional hazards models with spatially varying effects at sub-national scales were utilized to quantify associations between all-cause U5M and interventions at national and regional levels. Bayesian variable selection was employed to select the most important determinants of U5M. Results At the national level, interventions associated with the highest reduction in U5M were artemisinin-based combination therapy (hazard rate ratio (HRR) = 0.60; 95% Bayesian credible interval (BCI): 0.11, 0.79), initiation of breastfeeding within 1 h of birth (HR = 0.70; 95% BCI: 0.51, 0.86), intermittent preventive treatment (IPTp) (HRR = 0.74; 95% BCI: 0.67, 0.97) and access to insecticide-treated nets (ITN) (HRR = 0.75; 95% BCI: 0.63, 0.84). In Central 2, Mid-Western and South-West, largest reduction in U5M was associated with access to ITNs. In Mid-North and West-Nile, improved source of drinking water explained most of the U5M reduction. In North-East, improved sanitation facilities were associated with the highest decline in U5M. In Kampala and Mid-Eastern, IPTp had the largest associated with U5M. In Central1 and East-Central, oral rehydration solution and postnatal care were associated with highest decreases in U5M respectively. Conclusion Sub-national estimates of the associations between U5M and interventions can guide control programmes for spatial targeting and accelerate progress towards mortality-related Sustainable Development Goals.

Background As an important marker for health equity and access, under-five mortality (UFM) is a primary measure for socioeconomic development. The importance of reducing UFM has been further emphasized in an ambitious target under Sustainable Development Goals. The factors influencing UFM are not adequately understood in Bhutan. Methods The most recent dataset of the Bhutan National Health Survey (BNHS) 2012 was used in this study. Multiple logistic regression analysis using a backwards elimination approach was performed to identify significant factors influencing UFM. All statistical analyses were adjusted for the complex study design due to the multistage stratified cluster sampling used in BNHS. Results Bhutan’s UFM rate was 37 per 1000 live births. The weighted mean age of the children was 7.3 years (SD: 1.53; range: 3–12). Mother’s age, household size, access to electricity and sanitation, residential region, and parity were the key factors associated with UFM. The UFM risk was significantly lower in children born to mothers aged 36–40 years, 41–45 years, and > 45 years when compared to that in children born to mothers aged 5 members. Children born in households without electricity and safe sanitation had a significantly higher risk of death, by 81 and 49% respectively. Relative to those born in the west, children born in the central and eastern regions were 1.72 (95% CI: 1.07–2.77) and 2.09 (95% CI: 1.46–2.99) times more likely to die, respectively. Children born to mothers who gave birth to > 2 children were significantly more likely to die than their counterparts. Conclusion These findings suggest that younger mother’s age, the higher number of births and being born in the central and eastern regions are associated with a higher UFM risk, whereas a larger household size and access to electricity and safe sanitation are key factors associated with lower UFM risk in Bhutan. Women empowerment, health education and strategies promoting maternal and child health in rural areas need to be scaled-up. Additionally, socioeconomic development programs should seek to reduce regional disparities. Electronic supplementary material The online version of this article (10.1186/s12889-018-6308-6) contains supplementary material, which is available to authorized users.

Background Infant and child mortality rates are among the health indicators of importance in a given community or country. It is the fourth millennium development goal that by 2015, all the United Nations member countries are expected to have reduced their infant and child mortality rates by two-thirds. Uganda is one of those countries in Sub-Saharan Africa with high infant and child mortality rates, therefore it is important to use sound statistical methods to determine which factors are strongly associated with child mortality which in turn will help inform the design of intervention strategies Methods The Uganda Demographic Health Survey (UDHS) funded by USAID, UNFPA, UNICEF, Irish Aid and the United Kingdom government provides a data set which is rich in information on child mortality or survival. Survival analysis techniques are among the well-developed methods in Statistics for analysing time to event data. These methods were adopted in this paper to examine factors affecting under-five child mortality rates (UMR) in Uganda using the UDHS data for 2011 in R and STATA software. Results Results obtained by fitting the Cox-proportional hazard model with frailty effects and drawing inference using both the frequentists and Bayesian approaches at 5 % significance level, show evidence of the existence of unobserved heterogeneity at the household level but there was not enough evidence to conclude the existence of unobserved heterogeneity at the community level. Sex of the household head, sex of the child and number of births in the past one year were found to be significant. The results further suggest that over the period of 1990–2015, Uganda reduced its UMR by 52 % . Conclusion Uganda has not achieved the MDG4 target but the 52 % reduction in the UMR is a move in the positive direction. Demographic factors (sex of the household head) and Biological determinants (sex of the child and number of births in the past one year) are strongly associated with high UMR. Heterogeneity or unobserved covariates were found to be significant at the household but insignificant at the community level.

Background Improvements in child survival have been very poor in sub-Saharan Africa (SSA). Since the 1990s, declines in child mortality have reversed in many countries in the region, while in others, they have either slowed or stalled, making it improbable that the target of reducing child mortality by two thirds by 2015 will be reached. This paper highlights the implications of urban population growth and access to health and social services on progress in achieving MDG 4. Specifically, it examines trends in childhood mortality in SSA in relation to urban population growth, vaccination coverage and access to safe drinking water. Methods Correlation methods are used to analyze national-level data from the Demographic and Health Surveys and from the United Nations. The analysis is complemented by case studies on intra-urban health differences in Kenya and Zambia. Results Only five of the 22 countries included in the study have recorded declines in urban child mortality that are in line with the MDG target of about 4% per year; five others have recorded an increase; and the 12 remaining countries witnessed only minimal decline. More rapid rate of urban population growth is associated with negative trend in access to safe drinking water and in vaccination coverage, and ultimately to increasing or timid declines in child mortality. There is evidence of intra-urban disparities in child health in some countries like Kenya and Zambia. Conclusion Failing to appropriately target the growing sub-group of the urban poor and improve their living conditions and health status – which is an MDG target itself – may result in lack of improvement on national indicators of health. Sustained expansion of potable water supplies and vaccination coverage among the disadvantaged urban dwellers should be given priority in the efforts to achieve the child mortality MDG in SSA.

Background From 1995-2000 the under five mortality rate in Uganda increased from 147.3 to 151.5 deaths per 1000 live births and reasons for the increase were not clear. This study was undertaken to understand factors influencing the increase in under five mortality rate during 1995-2000 in Uganda with a view of suggesting remedial actions. Methods We performed a comparative retrospective analysis of data derived from the 1995 and the 2000 Uganda demographic and health surveys. We correlated the change of under five mortality rate in Uganda desegregated by region (central, eastern, north and western) with change in major known determinants of under five mortality such social economic circumstances, maternal factors, access to health services, and level of nutrition. Results The increase in under five mortality rate only happened in western Uganda with the other 3 regions of Uganda (eastern, northern and central) showing a decrease. The changes in U5MR could not be explained by changes in poverty, maternal conditions, level of nutrition, or in access to health and other social services and in the prevalence of HIV among women attending for ante-natal care. All these factors did not reach statistical significance (P > 0.05) using Pearson's correlation coefficient. Conclusion In order to explain these findings, there is need to find something that happened in western Uganda (but not other parts of the country) during the period 1995-2000 and has the potential to change the under five mortality by a big margin. We hypothesize that the increase in under five mortality could be explained by the severe malaria epidemic that occurred in western Uganda (but not other regions) in 1997/98.

Background Childhood mortality rate is high in Nigeria. There is dearth of information on the comparison of childhood mortality probability and its causal factors in the Northern and Southern Nigeria. This study was designed to fill these gaps. Methods Nigeria Demographic and Health Survey, 2008 data was used. The first part of this study focused on women aged 15–49 who ever given birth to a child (n = 23,404), irrespective of the survival status of the child and the second part utilized all women aged 15–49 (N = 33,385). The outcome variable was experienced childhood mortality. Data was analyzed using Chi-square, logistic regression and Brass logit model. Results Results showed that similar patterns of children’s death were observed in the two regions, but variation existed. Childhood mortality experienced was more pronounced in the North than the South, even when the potential confounding variables were used as control. Levels of education and wealth index showed an inverse relationship with childhood death in the regions (p 0.05), but the difference was significant in the South (p Conclusion Childhood mortality is higher in the Northern than Southern Nigeria. Improving women’s education, particularly in the North will alleviate childhood mortality in Nigeria.

BackgroundUndernutrition is a leading cause of child mortality in developing countries, especially in sub-Saharan Africa. We examine the household and community level socioeconomic and environmental factors associated with child nutritional status in Cameroon, and changes in the effects of these factors during the 1990s economic crisis. We further consider age-specific effects of household economic status on child nutrition.MethodsChild nutritional status was measured by weight-for-age (WAZ) and height-for-age (HAZ) z-scores. Data were from Demographic and Health Surveys conducted in 1991 and 1998. We used analysis of variance to assess the bivariate association between the explanatory factors and nutritional status. Multivariate, multilevel analyses were undertaken to estimate the net effects of both household and community factors.ResultsAverage WAZ and HAZ declined respectively from -0.70 standard deviations (SD), i.e. 0.70 SDbelowthe reference median, to -0.83 SD (p = 0.006) and from -1.03 SD to -1.14 SD (p = 0.026) between 1991 and 1998. These declines occurred mostly among boys, children over 12 months of age, and those of low socioeconomic status. Maternal education and maternal health seeking behavior were associated with better child nutrition. Household economic status had an overall positive effect that increased during the crisis, but it had little effect in children under 6 months of age. Improved household (water, sanitation and cooking fuel) and community environment had positive effects. Children living in the driest regions of the country were consistently worst off, and those in the largest cities were best off.ConclusionBoth household and community factors have significant impact on child health in Cameroon. Understanding these relationships can facilitate design of age- and community-specific intervention programs.

Background Global health equity strategists have previously focused much on differences across countries. At first glance, the global health gap appears to result primarily from disparities between the developing and developed regions. We examine how much of this disparity could be attributed to within-country disparities in developing nations. Methods We used data from Demographic and Health Surveys conducted between 1995 and 2010 in 67 developing countries. Using a population attributable risk approach, we computed the proportion of global under-five mortality gap and the absolute number of under-five deaths that would be reduced if the under-five mortality rate in each of these 67 countries was lowered to the level of the top 10% economic group in each country. As a sensitivity check, we also conducted comparable calculations using top 5% and the top 20% economic group. Results In 2007, approximately 6.6 million under-five deaths were observed in the 67 countries used in the analysis. This could be reduced to only 600,000 deaths if these countries had the same under-five mortality rate as developed countries. If the under-five mortality rate was lowered to the rate among the top 10% economic group in each of these countries, under-five deaths would be reduced to 3.7 million. This corresponds to a 48% reduction in the global mortality gap and 2.9 million under-five deaths averted. Using cutoff points of top 5% and top 20% economic groups showed reduction of 37% and 56% respectively in the global mortality gap. With these cutoff points, respectively 2.3 and 3.4 million under-five deaths would be averted. Conclusion Under-five mortality disparities within developing countries account for roughly half of the global gap between developed and developing countries. Thus, within-country inequities deserve as much consideration as do inequalities between the world’s developing and developed regions.

Background To reach global and national goals for maternal and child mortality, countries must identify vulnerable populations, which includes sex workers and their children. The objective of this study was to identify and describe maternal deaths of female sex workers in Cambodia and causes of death among their children. Methods A convenience sample of female sex workers were recruited by local NGOs that provide support to sex workers. We modified the maternal mortality section of the 2010 Cambodia Demographic and Health Survey and collected reports of all deaths of female sex workers. For each death we ask the ‘sisterhood’ methodology questions to identify maternal deaths. For child deaths we asked each mother who reported the death of a child about the cause of death. We also asked all participants about the cause of deaths of children of other female sex workers. Results We interviewed 271 female sex workers in the four largest Cambodian cities between May and September 2013. Participants reported 32 deaths of other female sex workers that met criteria for maternal death. The most common reported causes of maternal deaths were abortion (n = 13;40%) and HIV (n = 5;16%). Participants report deaths of 8 of their children and 50 deaths of children of other female sex workers. HIV was the reported cause of death for 13 (36%) children under age five. Conclusion This is the first report of maternal deaths of sex workers in Cambodia or any other country. This modification of the sisterhood methodology has not been validated and did not allow us to calculate maternal mortality rates so the results are not generalizable, however these deaths may represent unrecognized maternal deaths in Cambodia. The results also indicate that children of sex workers in Cambodia are at risk of HIV and may not be accessing treatment. These issues require additional studies but in the meantime we must assure that sex workers in Cambodia and their children have access to quality health services.

Background The Kenya Demographic and Health Surveys (KDHS) data collected since 1989 indicate that malaria prone areas have consistently recorded the highest childhood mortality rates. Malaria control programme information also indicates that malaria contributes to about 20 per cent of the deaths among under-five year old children. The 2009–2017 National Malaria Strategy is being implemented to reduce malaria morbidity and mortality. Its key interventions include: bed nets use; anti-malaria drugs use during pregnancy for prevention; and, prompt treatment using anti-malaria drugs of children with fever. This study seeks to establish differentials in childhood mortality rates by these interventions in three malaria prone areas defined as highland epidemic, coast endemic and lake endemic. It also seeks to determine the effects of these interventions on childhood mortality. Methods The data used is drawn from the 2008/9 KDHS. The study sample consists of 3,728 children born less than 60 months prior to the survey. The direct demographic method for estimation of childhood mortality rates and multivariate Poisson regression models are used to analyse the data. Results The findings show that use of bed nets and anti-malaria drugs are not high in Kenya’s malaria prone areas. On the average, only about 60% of the children are found to be in higher use category for each of the three intervention measures. The childhood mortality rates show that higher use of prompt treatment with anti-malaria drugs for children with fever has lower infant and under-five mortality rates in all malaria epidemic and endemic areas compared to lower use. Higher bed nets use has lower childhood mortality rates compared to lower use in coast and lake endemic areas. Higher use of anti-malaria drugs during pregnancy for prevention has lower childhood mortality rates in highland epidemic and lake endemic areas compared to lower use. The regression models fitted show that in highland epidemic area, higher use of anti-malaria drugs during pregnancy for prevention has significant reduction effect on childhood mortality compared to lower use in the presence of breastfeeding duration, toilet facility type and age of child variables. The regression models also show that in combined malaria prone areas, higher prompt treatment of children with fever using anti-malaria drugs has significant reduction effect on both infant and child mortality compared to lower prompt treatment in the presence of breastfeeding duration and toilet facility type variables. Conclusion This study underscore the need for increasing uptake of malaria interventions and complementing them with longer breastfeeding duration and improved toilet facility in efforts towards reducing infant and child mortality rates in Kenya’s malaria prone areas. There is also need to improve quality of individual household data for malaria module in future KDHS undertakings.

Background\ud The child mortality rate is a good indicator of development. High levels of infectious diseases and high child mortality make the Democratic Republic of Congo (DRC) one of the most challenging environments for health development in Sub-Saharan Africa (SSA). Recent conflicts in the eastern part of the country and bad governance have compounded the problem. This study aimed to examine province-level geographic variation in under-five mortality (U5M), accounting for individual- and household-level risk factors including environmental factors such as conflict.\ud \ud Methods\ud Our analysis used the nationally representative cross-sectional household sample of 8,992 children under five in the 2007 DRC Demographic and Health Survey. In the survey year, 1,005 deaths among this group were observed. Information on U5M was aggregated to the 11 provinces, and a Bayesian geo-additive discrete-time survival mixed model was used to map the geographic distribution of under-five mortality rates (U5MRs) at the province level, accounting for observable and unobservable risk factors.\ud \ud Results\ud The overall U5MR was 159 per 1,000 live births. Significant associations with risk of U5M were found for