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Background: Despite global achievements in reducing early childhood mortality, disparities remain. There have been empirical studies of inequalities conducted in low- and middle-income countries. However, there have been no epidemiological studies on socioeconomic inequalities and early childhood survival in Myanmar. Objective: To estimate associations between two measures of parental socioeconomic status – household wealth and education – and age-specific early childhood mortality in Myanmar. Methods: Using cross-sectional data obtained from the Myanmar Demographic Health Survey (2015–2016), univariate and multiple logistic regressions were performed to investigate associations between household wealth and highest attained parental education, and under-5, neonatal, post-neonatal and child mortality. Data for 10,081 children born to 5,932 married women (aged 15–49 years) 10 years prior to the survey, were analysed. Results: Mortality during the first five years was associated with household wealth. In multiple logistic models, wealth was protective for post-neonatal mortality. After adjusting for individual proximate determinants, the odds of post-neonatal mortality in the richest households were 85% lower (95% CI: 50–96%) than in the poorest households. However, significant association was not found between wealth and neonatal mortality. Parental education was important for early childhood mortality; the highest benefit from parental education was for child mortality in the one- to five-year age bracket. After adjusting for proximate determinants, children with a higher educated parent had 95% (95% CI 77–99%) lower odds of death in this age group compared with children whose parents' highest educational attainment was at primary level. The association between parental education and neonatal mortality was not significant. Conclusions: In Myanmar, household wealth and parental education are important for childhood survival before five years of age. This study identified nuanced age-related differences in associations. Health policy must take socioeconomic determinants into account in order to address unfair inequalities in early childhood mortality. [ABSTRACT FROM AUTHOR]

Introduction: Achieving a fair and equitable distribution of health in the population while progressing toward universal health coverage (UHC) is a key focus of health policy in Vietnam. This paper describes health barriers experienced by women (and children by inference) in Vietnam, and measures how UHC, with reference to maternal health services and child mortality rates, is affected by selected social determinants of health (SDH), termed 'barriers'. Methods: Our study uses a cross-sectional design with data from the 2011 Vietnam Multiple Indicator Cluster Survey. The study sample includes 11,663 women, aged 15-49 years. Weighted frequency statistics are cross-tabulated with socioeconomic characteristics of the population to describe the extent and distribution of health barriers experienced by disadvantaged women and children in Vietnam. A subset of women who had a live birth in the preceding two years (n_1,383) was studied to assess the impact of barriers to UHC and health. Six multiple logistic regressions were run using three dependent variables in the previous two years: 1) antenatal care, 2) skilled birth attendants, and 3) child death in the previous 15 years. Independent predictor variables were: 1) low education (incomplete secondary education), 2) lack of access to one of four basic amenities. In a second set of regressions, a constructed composite barrier index replaced these variables. Odds ratios (ORs) and 95% confidence intervals (95% CI) were used to report regression results. Results: In Vietnam, about 54% of women aged 15-49 years in 2011, had low education or lacked access to one of four basic amenities. About 38% of poor rural women from ethnic minorities experienced both barriers, compared with less than 1% of rich urban women from the ethnic majority. Incomplete secondary education or lack of one of four basic amenities was a factor significantly associated with lower access to skilled birth attendants (OR_0.28, 95% CI: 0.14-0.55; OR-0.19, 95% CI: 0.05-0.80) and a higher risk of having had a child death in the previous two years (OR-1.71, 95% CI: 1.28_2.30; OR-1.59, 95% CI: 1.20-2.10). Conclusions: Our study shows the need for accelerating education and infrastructure investments for ethnic minority communities living in rural areas so as to be able to contribute to equity-oriented progress toward UHC. [ABSTRACT FROM AUTHOR]

Background: Several epidemiological studies from low- and middle-income countries have reported a protective effect of maternal antenatal iron/folic acid (IFA) on childhood mortality. Objective: The current study aimed to evaluate the effect of maternal antenatal IFA supplementation on childhood mortality in Pakistan. Design: A propensity score-matched sample of 8,512 infants live-born within the 5 years prior to interview was selected from the pooled data of two Pakistan Demographic and Health Surveys (2006/07 and 2012/13). The primary outcomes were childhood mortality indicators and the main exposure variable was maternal antenatal IFA supplementation. Post-matched analyses used Cox proportional hazards regression and adjusted for 16 potential confounders. Results: Maternal antenatal IFA supplementation significantly reduced the adjusted risk of death on day 0 by 33% [adjusted hazard ratio (aHR) = 0.67, 95% confidence interval (95% CI) 0.48-0.94], during the neonatal period by 29% (aHR = 0.71, 95% CI 0.57-0.88), and for under-fives by 27% (aHR = 0.73, 95% CI 0.60-0.89). When IFA was initiated in the first 4 months of pregnancy, the adjusted risk of neonatal and under-five deaths was significantly reduced by 35 and 33%, respectively. Twenty percent of under-five deaths were attributable to non-initiation of IFA in the first 4 months of pregnancy. With universal initiation of IFA in the first 4 months of pregnancy, 80,300 under-five deaths could be prevented annually in Pakistan. Conclusions: Maternal antenatal IFA supplementation significantly reduced neonatal and under-five deaths in Pakistan. Earlier initiation of supplements in pregnancy was associated with a greater prevention of neonatal and under-five deaths. [ABSTRACT FROM AUTHOR]

Introduction: Achieving a fair and equitable distribution of health in the population while progressing toward universal health coverage (UHC) is a key focus of health policy in Vietnam. This paper describes health barriers experienced by women (and children by inference) in Vietnam, and measures how UHC, with reference to maternal health services and child mortality rates, is affected by selected social determinants of health (SDH), termed 'barriers'. Methods: Our study uses a cross-sectional design with data from the 2011 Vietnam Multiple Indicator Cluster Survey. The study sample includes 11,663 women, aged 15-49 years. Weighted frequency statistics are crosstabulated with socioeconomic characteristics of the population to describe the extent and distribution of health barriers experienced by disadvantaged women and children in Vietnam. A subset of women who had a live birth in the preceding two years (n = 1,383) was studied to assess the impact of barriers to UHC and health. Six multiple logistic regressions were run using three dependent variables in the previous two years: 1) antenatal care, 2) skilled birth attendants, and 3) child death in the previous 15 years. Independent predictor variables were: 1) low education (incomplete secondary education), 2) lack of access to one of four basic amenities. In a second set of regressions, a constructed composite barrier index replaced these variables. Odds ratios (ORs) and 95% confidence intervals (95% CI) were used to report regression results. Results: In Vietnam, about 54% of women aged 15-49 years in 2011, had low education or lacked access to one of four basic amenities. About 38% of poor rural women from ethnic minorities experienced both barriers, compared with less than 1% of rich urban women from the ethnic majority. Incomplete secondary education or lack of one of four basic amenities was a factor significantly associated with lower access to skilled birth attendants (OR =0.28, 95% CI: 0.14-0.55; OR =0.19, 95% CI: 0.05-0.80) and a higher risk of having had a child death in the previous two years (OR = 1.71, 95% CI: 1.28-2.30; OR = 1.59, 95% CI: 1.20-2.10). Conclusions: Our study shows the need for accelerating education and infrastructure investments for ethnic minority communities living in rural areas so as to be able to contribute to equity-oriented progress toward UHC. [ABSTRACT FROM AUTHOR]

Background: Recent steep declines in child mortality have been attributed in part to increased use of contraceptives and the resulting change in fertility behaviour, including an increase in the time between births. Previous observational studies have documented strong associations between short birth spacing and an increase in the risk of neonatal, infant, and under-five mortality, compared to births with longer preceding birth intervals. In this analysis, we compare two methods to estimate the association between short birth intervals and mortality risk to better inform modelling efforts linking family planning and mortality in children. Objectives: Our goal was to estimate the mortality risk for neonates, infants, and young children by preceding birth space using household survey data, controlling for mother-level factors and to compare the results to those from previous analyses with survey data. Design: We assessed the potential for confounding when estimating the relative mortality risk by preceding birth interval and estimated mortality risk by birth interval in four categories-less than 18 months, 18-23 months, 24-35 months, and 36 months or longer. We estimated the relative risks among women who were 35 and older at the time of the survey with two methods- in a Cox proportional hazards regression adjusting for potential confounders and also by stratifying Cox regression by mother, to control for all factors that remain constant over a woman's childbearing years. We estimated the overall effects for birth spacing in a meta-analysis with random survey effects. Results: We identified several factors known for their associations with neonatal, infant, and child mortality that are also associated with preceding birth interval. When estimating the effect of birth spacing on mortality, we found that regression adjustment for these factors does not substantially change the risk ratio for short birth intervals compared to an unadjusted mortality ratio. For birth intervals less than 18 months, standard regression adjustment for confounding factors estimated a risk ratio for neonatal mortality of 2.28 (95% confidence interval- 2.18-2.37). This same effect estimated within mother is 1.57 (95% confidence interval- 1.52-1.63), a decline of almost one-third in the effect on neonatal mortality. Conclusions: Neonatal, infant, and child mortality are strongly and significantly related to preceding birth interval, where births within a short interval of time after the previous birth have increased mortality. Previous analyses have demonstrated this relationship on average across all births; however, women who have short spaces between births are different from women with long spaces. Among women 35 years and older where a comparison of birth spaces within mother is possible, we find a much reduced although still significant effect of short birth spaces on child mortality. [ABSTRACT FROM AUTHOR]

Objective: To estimate and evaluate the cause-of-death structure and disease-specific mortality rates in a rural area of The Gambia as determined using the InterVA-4 model. Design: Deaths and person-years of observation were determined by age group for the population of the Farafenni Health and Demographic Surveillance area from January 1998 to December 2007. Causes of death were determined by verbal autopsy (VA) using the InterVA-4 model and ICD-10 disease classification. Assigned causes of death were classified into six broad groups: infectious and parasitic diseases; cancers; other non-communicable diseases; neonatal; maternal; and external causes. Poisson regression was used to estimate age and disease-specific mortality rates, and likelihood ratio tests were used to determine statistical significance. Results: A total of 3,203 deaths were recorded and VA administered for 2,275 (71%). All-age mortality declined from 15 per 1,000 person-years in 1998-2001 to 8 per 1,000 person-years in 2005-2007. Children aged 1-4 years registered the most marked (74%) decline from 27 to 7 per 1,000 person-years. Communicable diseases accounted for half (49.9%) of the deaths in all age groups, dominated by acute respiratory infections (ARI) (13.7%), malaria (12.9%) and pulmonary tuberculosis (10.2%). The leading causes of death among infants were ARI (5.59 per 1,000 person-years [95% CI: 4.38-7.15]) and malaria (4.11 per 1,000 person-years [95% CI: 3.09-5.47]). Mortality rates in children aged 1-4 years were 3.06 per 1,000 person-years (95% CI: 2.58-3.63) for malaria, and 1.05 per 1,000 person-years (95% CI: 0.79-1.41) for ARI. The HIV-related mortality rate in this age group was 1.17 per 1,000 person-years (95% CI: 0.89-1.54). Pulmonary tuberculosis and communicable diseases other than malaria, HIV/AIDS and ARI were the main killers of adults aged 15 years and over. Strokerelated mortality increased to become the leading cause of death among the elderly aged 60 years or more in 2005-2007. Conclusions: Mortality in the Farafenni HDSS area was dominated by communicable diseases. Malaria and ARI were the leading causes of death in the general population. In addition to these, diarrhoeal disease was a particularly important cause of death among children under 5 years of age, as was pulmonary tuberculosis among adults aged 15 years and above. [ABSTRACT FROM AUTHOR]

Background: Disparities in health outcomes between the poor and the better off are increasingly attracting attention from researchers and policy makers. However, policies aimed at reducing inequity need to be based on evidence of their nature, magnitude, and determinants. Objectives: The study aims to investigate the relationship between household socio-economic status (SES) and under-five mortality, and to measure health inequality by comparing poorest/least poor quintile mortality rate ratio and the use of a mortality concentration index. It also aims to describe the risk factors associated with under-five mortality at Rufiji Demographic Surveillance Site (RDSS), Tanzania. Methods: This analytical cross sectional study included 11,189 children under-five residing in 7,298 households in RDSS in 2005. Principal component analysis was used to construct household SES. Kaplan-Meier survival incidence estimates were used for mortality rates. Health inequality was measured by calculating and comparing mortality rates between the poorest and least poor wealth quintile. We also computed a mortality concentration index. Risk factors of child mortality were assessed using Poisson regression taking into account potential confounders. Results: Under-five mortality was 26.9 per 1,000 person-years [95% confidence interval (CI) (23.7-30.4)]. The poorest were 2.4 times more likely to die compared to the least poor. Our mortality concentration index [-0.16; 95% CI (-0.24, -0.08)] indicated considerable health inequality. Least poor households had a 52% reduced mortality risk [incidence rate ratio (IRR) = 0.48; 95% CI 0.30-0.80]. Furthermore, children with mothers who had attained secondary education had a 70% reduced risk of dying compared to mothers with no education [IRR = 0.30; 95% CI (0.22-0.88)]. Conclusion: Household socio-economic inequality and maternal education were associated with under-five mortality in the RDSS. Targeted interventions to address these factors may contribute towards accelerating the reduction of child mortality in rural Tanzania. [ABSTRACT FROM AUTHOR]

Background: South Africa accounts for more than a sixth of the global population of people infected with HIV and TB, ranking her highest in HIV/TB co-infection worldwide. Remote areas often bear the greatest burden of morbidity and mortality, yet there are spatial differences within rural settings. Objectives: The primary aim was to investigate HIV/TB mortality determinants and their spatial distribution in the rural Agincourt sub-district for children aged 1-5 years in 2004. Our secondary aim was to model how the associated factors were interrelated as either underlying or proximate factors of child mortality using pathway analysis based on a Mosley-Chen conceptual framework. Methods: We conducted a secondary data analysis based on cross-sectional data collected in 2004 from the Agincourt sub-district in rural northeast South Africa. Child HIV/TB death was the outcome measure derived from physician assessed verbal autopsy. Modelling used multiple logit regression models with and without spatial household random effects. Structural equation models were used in modelling the complex relationships between multiple exposures and the outcome (child HIV/TB mortality) as relayed on a conceptual framework. Results: Fifty-four of 6,692 children aged 1-5 years died of HIV/TB, from a total of 5,084 households. Maternal death had the greatest effect on child HIV/TB mortality (adjusted odds ratio=4.00; 95% confidence interval=1.01-15.80). A protective effect was found in households with better socio-economic status and when the child was older. Spatial models disclosed that the areas which experienced the greatest child HIV/TB mortality were those without any health facility. Conclusion: Low socio-economic status and maternal deaths impacted indirectly and directly on child mortality, respectively. These factors are major concerns locally and should be used in formulating interventions to reduce child mortality. Spatial prediction maps can guide policy makers to target interventions where they are most needed. [ABSTRACT FROM AUTHOR]

There is increasing concern regarding adverse effects of prenatal arsenic exposure on the neurodevelopment of children. We analyzed mortality data for children, who were born to 11,414 pregnant women between 2002 and 2004, with an average age of 5 years of follow-up. Individual drinking-water arsenic exposure during pregnancy was calculated using tubewell water arsenic concentration between last menstrual period and date of birth. There were 84 drowning deaths registered, with cause of death ascertained using verbal autopsy (International Classification of Diseases, 10th revision, codes X65-X70). The prenatal water arsenic exposure distribution was tertiled, and the risk of drowning mortality was estimated by Cox proportional hazard models, adjusted for potential confounders. We observed a significant association between prenatal arsenic exposure and drowning in children aged 1-5 years in the highest exposure tertile (HR=1.74, 95% CI: 1.03-2.94). This study showed that in utero arsenic exposure might be associated with excess mortality among children aged 1-5 years due to drowning. [ABSTRACT FROM AUTHOR]