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Between 2018 and 2022 the Liberian Government implemented the National Community Health Assistant (NCHA) program to improve provision of maternal and child health care to underserved rural areas of the country. Whereas the contributions of this and similar community health worker (CHW) based healthcare programs have been associated with improved process measures, the impact of a governmental CHW program at scale on child mortality has not been fully established. We will conduct a cluster sampled, community-based survey with landmark event calendars to retrospectively assess child births and deaths among all children born to women in the Grand Bassa District of Liberia. We will use a mixed effects Cox proportional hazards model, taking advantage of the staggered program implementation in Grand Bassa districts over a period of 4 years to compare rates of under-5 child mortality between the pre- and post-NCHA program implementation periods. This study will be the first to estimate the impact of the Liberian NCHA program on under-5 mortality., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Jockers et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Under-five mortality (U5M) is considered a major public health issue directly impacts a country's development. This study analyzed the prognostic factors of U5M in Sri Lanka using data from the 2016 Demographic and Health Survey (DHS) of 8123 children. The study employed both a binary logistic regression model (BLRM) and a binary logistic random intercept multilevel model (BLRIMM) and compared the accuracy of each model's prediction percentage. The results showed that the BLRIMM had a higher correct prediction percentage (98.67%) compared to the BLRM (98.31%). The study found that children who were not breastfed (Odds Ratio (OR) = 116.74, 95% Confidence Interval (CI) = 62.97-216.41), were part of multiple births (OR = 3.73, 95% CI = 1.21-11.51), did not have a normal delivery (OR = 1.86, 95% CI = 1.11-3.12), were born to mothers who had experienced previous miscarriages or child loss (OR = 2.27, 95% CI = 1.26-4.11), and were born to mothers with a higher Body Mass Index (BMI) (OR = 1.05, 95% CI = 1.003-1.10) had higher odds of U5M. The odds of U5M were found to be lower among Buddhists (OR = 0.06, 95% CI = 0.01-0.50), Hindus (OR = 0.05, 95% CI = 0.01-0.46), and Roman Catholics (OR = 0.032, 95% CI = 0.003-0.307) compared to the "Other Religions" category in the dataset. The estimated covariance parameter of the random intercept (0.8231, p-value = 0.0405) indicated significant unobserved cluster-level variation in U5M. The study's results emphasize the importance of addressing religion related differences of U5M and improving maternal education regarding healthy lifestyle, proper food intake, the significance of breastfeeding, safe delivery methods, safety measures during pregnancy and childbirth in cases of multiple births, and proper child care after birth., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Thabrew et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Sustainable Development Goal 3.2 (SDG 3.2) is to reduce Under-5 and neonatal mortality rates (U5MR and NMR), two major health systems' performance indicators, globally by 2030. We aimed to report Iran's U5MR and NMR status during 2010-2017 and its achievement of SDG 3.2 by 2030, using scenario-based projection., Study Design: To estimate the national and subnational levels of U5MR and NMR, we applied an Ensemble Bayesian Model Averaging (EBMA) with Gaussian Process Regression (GPR) and Spatio_temporal models. We used all available data sources including: 12-year data from the Death Registration System (DRS), two censuses, and a demographic and health surveys (DHS). This study employed two approaches, Maternal Age Cohort (MAC) and Maternal Age Period (MAP), to analyze summary birth history data obtained from censuses and DHS. In addition, we calculated the child mortality rate directly from DHS using the complete birth history method. National and subnational NMR was projected up to 2030 with a scenario-based method using average Annual Rate of Reduction (ARR) introduced by UN-IGME., Results: In 2017, national U5MR and NMR were 15·2 (12·4-18·0) and 11·8 (10·4-13·2), with an average ARR of 5·1% (2·1-8·9) and 3·1% (0·9-5·8) during 2010-2017, respectively. According to our projection scenarios, 17 provinces have not fulfilled SDG 3.2 for NMR yet, and the current trend (the current trend of NMR improvement in Iran) will not result in reaching SDG for some provinces by 2030; However, if each province has the same neonatal mortality annual reduction rate as the best-performing province in the same region, besides achieving SDG, the national NMR will be reduced to 5·2, and almost 92,000 newborn lives will be saved., Conclusions: Iran has achieved SDG3.2 regarding U5MR and NMR; however, there are provincial inequalities. For all provinces to reach SDG3.2, health policies should focus on reducing provincial inequalities by precise planning for neonatal health care., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Ebrahimi et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: The death of children under-five years is one of the critical issues in public health and improving child survival continues to be a matter of urgent concern. In this paper, we assessed the proximate and socio-economics determinants of child mortality in Guinea., Methods: Using the 2018 Guinea Demographic and Health Survey (GDHS), we extracted demographic and mortality data of 4,400 children under-five years. Both descriptive and multivariable logistic regression analyses were conducted., Results: Under-five mortality was 111 deaths per 1,000 live births in Guinea. The likelihood of death was higher among children born to mothers who belong to other religions compared to Christians (aOR = 2.86, 95% CI: 1.10-7.41), smaller than average children compared to larger than average children (aOR = 1.97, 95% CI: 1.28-3.04) and those whose mothers had no postnatal check-up visits after delivery (aOR = 1.72, 95% CI: 1.13-2.63). Conversely, the odds of death in children with 2-3 birth rank & >2 years of birth interval compared to ≥4 birth rank and ≤2 years of birth interval were low (aOR = 0.53, 95% CI: 0.34-0.83)., Conclusion: We found that household/individual-level socioeconomic and proximate factors predict under-five mortality in Guinea. With just about a decade left to the 2030 deadline of the Sustainable Development Goals (SDGs), concerted efforts across all key stakeholders, including government and development partners, need to be geared towards implementing interventions that target these predictors., Competing Interests: The authors have declared that no competing interests exist.

Background: Goal 3.2 from the Sustainable Development Goals (SDG) calls for reductions in national averages of Under-5 Mortality. However, it is well known that within countries these reductions can coexist with left behind populations that have mortality rates higher than national averages. To measure inequality in under-5 mortality and to identify left behind populations, mortality rates are often disaggregated by socioeconomic status within countries. While socioeconomic disparities are important, this approach does not quantify within group variability since births from the same socioeconomic group may have different mortality risks. This is the case because mortality risk depends on several risk factors and their interactions and births from the same socioeconomic group may have different risk factor combinations. Therefore mortality risk can be highly variable within socioeconomic groups. We develop a comprehensive approach using information from multiple risk factors simultaneously to measure inequality in mortality and to identify left behind populations., Methods: We use Demographic and Health Surveys (DHS) data on 1,691,039 births from 182 different surveys from 67 low and middle income countries, 51 of which had at least two surveys. We estimate mortality risk for each child in the data using a Bayesian hierarchical logistic regression model. We include commonly used risk factors for monitoring inequality in early life mortality for the SDG as well as their interactions. We quantify variability in mortality risk within and between socioeconomic groups and describe the highest risk sub-populations., Findings: For all countries there is more variability in mortality within socioeconomic groups than between them. Within countries, socioeconomic membership usually explains less than 20% of the total variation in mortality risk. In contrast, country of birth explains 19% of the total variance in mortality risk. Targeting the 20% highest risk children based on our model better identifies under-5 deaths than targeting the 20% poorest. For all surveys, we report efficiency gains from 26% in Mali to 578% in Guyana. High risk births tend to be births from mothers who are in the lowest socioeconomic group, live in rural areas and/or have already experienced a prior death of a child., Interpretation: While important, differences in under-5 mortality across socioeconomic groups do not explain most of overall inequality in mortality risk because births from the same socioeconomic groups have different mortality risks. Similarly, policy makers can reach the highest risk children by targeting births based on several risk factors (socioeconomic status, residing in rural areas, having a previous death of a child and more) instead of using a single risk factor such as socioeconomic status. We suggest that researchers and policy makers monitor inequality in under-5 mortality using multiple risk factors simultaneously, quantifying inequality as a function of several risk factors to identify left behind populations in need of policy interventions and to help monitor progress toward the SDG., Competing Interests: The authors have declared that no competing interests exist.

Background: Globally, the under-10 years of age mortality has not been comprehensively studied. We applied the life-course perspective in the analysis and interpretation of the event history demographic and verbal autopsy data to examine when and why children die before their 10th birthday., Methods: We analysed a decade (2005-2015) of event histories data on 22385 and 1815 verbal autopsies data collected by Iganga-Mayuge HDSS in eastern Uganda. We used the lifetable for mortality estimates and patterns, and Royston-Parmar survival analysis approach for mortality risk factors' assessment., Results: The under-10 and 5-9 years of age mortality probabilities were 129 (95% Confidence Interval [CI] = 123-370) per 1000 live births and 11 (95% CI = 7-26) per 1000 children aged 5-9 years, respectively. The top four causes of new-born mortality and stillbirth were antepartum maternal complications (31%), intrapartum-related causes including birth injury, asphyxia and obstructed labour (25%), Low Birth Weight (LBW) and prematurity (20%), and other unidentified perinatal mortality causes (18%). Malaria, protein deficiency including anaemia, diarrhoea or gastrointestinal, and acute respiratory infections were the major causes of mortality among those aged 0-9 years-contributing 88%, 88% and 46% of all causes of mortality for the post-neonatal, child and 5-9 years of age respectively. 33% of all causes of mortality among those aged 5-9 years was a share of Injuries (22%) and gastrointestinal (11%). Regarding the deterministic pattern, nearly 30% of the new-borns and sick children died without access to formal care. Access to the treatment for the top five morbidities was after 4 days of symptoms' recognition. The childhood mortality risk factors were LBW, multiple births, having no partner, adolescence age, rural residence, low education level and belonging to a poor household, but their association was stronger among infants., Conclusions: We have identified the vulnerable groups at risk of mortality as LBW children, multiple births, rural dwellers, those whose mother are of low socio-economic position, adolescents and unmarried. The differences in causes of mortalities between children aged 0-5 and 5-9 years were noted. These findings suggest for a strong life-course approach in the design and implementation of child health interventions that target pregnant women and children of all ages., Competing Interests: The authors have declared that no competing interests exist.

Background: In The Gambia, national estimates of under-five mortality (U5M) were from censuses and multiple indicator cluster surveys (MICS). The country's first demographic and health survey (DHS) conducted in 2013 provided empirical disaggregated national estimates of neonatal, post-neonatal and child mortality trends., Objective: To assess the consistency and accuracy of the estimates of U5M from the existing data sources and its age-specific components in rural Gambia and produce reliable up-to-date estimates., Methods: Available national data on under-five mortality from 2000 onwards were extracted. Additionally, data from two DHS regions were compared to those from two health and demographic surveillance systems (HDSS) located within them. Indirect and direct estimates from the data were compared and flexible parametric survival methods used to predict mortality rates for all empirical data points up to 2015., Findings: Internal consistency checks on data quality for indirect estimation of U5M suggest that the data were plausible at national level once information from women aged 15-19 years was excluded. The DHS and HDSS data used to make direct U5M estimates were plausible, however HDSS data were of better quality. For 2009-2013, the DHS estimates agreed well with the 2013 census and 2010 MICS reports of U5M but was less accurate about the early births of older women. The most recent estimates from the 2013 DHS, which refer to 2011-12, are an U5M rate of 54/1000 livebirths (95% CI: 43-64) and a neonatal mortality rate of 21/1000 livebirths (95% CI: 15-27), contributing almost 40% of U5M in The Gambia. The DHS showed that for the decade prior to the survey, child mortality dropped by 55% and neonatal mortality by 31%. This indicates the importance of neonatal mortality in The Gambia, and the need to focus on neonatal survival, while maintaining currently successful strategies to further reduce U5M., Competing Interests: The authors have declared that no competing interests exist.

Background: Sexual autonomy empowers women to set boundaries, take control of their bodies, prevent sexually transmitted diseases and avoid unplanned pregnancy. A woman's ability to negotiate safer sex is crucial for her survival and that of her child. Sexual autonomy among East African women is vital to the elimination of the deaths of neonates, infants, and children. The aim of our study was to explore the association of sexual autonomy on neonatal, infant, and child mortality., Methodology: This was a secondary analysis of demographic health survey (DHS) data on women of reproductive age (15-49 years) in five East African countries: Burundi, Kenya, Rwanda, Tanzania, and Uganda. Data on our outcome variables neonatal, infant, and under-five mortality which were in binary form was extracted from the database. Sexual autonomy was classified as a composite variable of "respondent can refuse sex," "respondent can ask partner to use condom," and "if spouse is justified in asking husband to use condom." Other sociodemographic, maternal, health system and paternal variables were included in the analysis. STATA version 14 was used for analysis. Proportions and frequencies were used to describe the three outcome variables and sociodemographic characteristics. Chi-square tests were used to compare associations between sexual autonomy and categorical variables. Adjusted hazard ratios were used to determine the association between sexual autonomy and independent variables., Results: The sampled women were predominantly urban (75%; n = 5758) and poor (48.7%; n = 3702). A majority of those that experienced mortality (neonatal mortality 53.5%, infant mortality 54.3%, under-five mortality 55.7%) were young (under 20) at the time of their first child's birth while their male partners were older. The multivariate analysis supports the beneficial effects of women's sexual autonomy in East Africa. Women who exercised sexual autonomy experienced significantly lower rates of child mortality at all three stages: neonatal (NHR = 0.80, 95% CI: 0.68-0.94, p = 0.006), infant (IHR = 0.82, 95% CI: 0.72-0.93, p = 0.003), and under-five (UHR = 0.84, 95% CI: 0.75-0.94, p = 0.002), net of all other factors. Receiving antenatal care and using contraceptives also contributed significantly to lower child mortality rates., Conclusion: Our findings suggest that sexual autonomy among East African women is an urgent priority that is crucial to the survival of neonates, infants, and children in East Africa. Women should be informed, empowered, and autonomous concerning their reproductive and sexual health., Competing Interests: The authors have declared that no competing interests exist.

Introduction: Despite global progress, there remains a disproportionate burden of under-five year old deaths in sub-Saharan Africa (SSA), where four out of five child deaths occur. Substantial progress has been made in improving sanitation, controlling communicable diseases and the spread of HIV in most parts of the world. However, significant strides to address some key risk factors related to under-five mortality are still needed in rural SSA if they are to attain relevant 2030 SDG targets. The aim of this study is to investigate the risk factors for under-five mortality in an HIV hyper-endemic area of rural South Africa, from 2000-2014. Some of the key risk factors investigated are, for example: household wealth, source of drinking water, distance to the national road and birth order., Methods: We conducted a statistical analysis of 759 births from a population-based cohort in rural KwaZulu-Natal Province, South Africa, from 2000 to 2014. A Cox Proportional Hazards model was used to identify the risk factors and key socio-demographic correlates of under-five mortality leveraging the longitudinal structure of the population cohort., Results: Child mortality rates declined by 80 per cent from 2000 to 2014, from >140 per 1,000 persons in years 2001-2003 to 20 per 1,000 persons in the year 2014. The highest under-five mortality rate was recorded in 2002/2003, which decreased following the start of antiretroviral therapy rollout in 2003/4. The results indicated that under-five and infant mortality are significantly associated with a low wealth index of 1.49 (1.007-2.48) for under-fives and 3.03 (1.72-5.34) for infants. Children and infants with a lower wealth index had a significantly increased risk of mortality as compared to those with a high wealth index. Other significant factors included: source of household drinking water (borehole) 3.03 (1.72-5.34) for under-fives and 2.98 (1.62-5.49) for infants; having an HIV positive mother 4.22 (2.68-6.65) for under-fives and 3.26 (1.93-5.51) for infants, and period of death 9.13 (5.70-14.6) for under-fives and 1.28 (0.75-2.20) for infants. Wealth index had the largest population attributable fraction of 25.4 per cent., Conclusions: The research findings show a substantial overall reduction in under-five mortality since 2003. Unsafe household water sources and having an HIV-positive mother were associated with an increased risk of under-five mortality in this rural setting. The significant risk factors identified align well with the SDG 2030 targets for reducing child mortality, which include improved nutrition, sanitation, hygiene and reduced HIV infections. Current trajectories suggest that there is some hope for meeting the 2030 SGD targets in rural South Africa and the region if the identified significant risk factors are adequately addressed., Competing Interests: The authors have declared that no competing interests exist.

Introduction: Childhood mortality remains a pressing problem in rural Kenya, and reducing under-five deaths is a key target of the Sustainable Development Goals. We aim to describe the reduction in under-five mortality in a rural Kenyan community served by the Lwala Community Alliance and factors associated with under-five mortality in this community., Methods: A cross-sectional survey containing a complete birth history was administered to a representative sample of the catchment area of the Lwala Community Alliance. Survival analysis techniques were used to describe temporal trends and risk factors related to under-five mortality., Results: 1,362 children were included in the study, and 91 children died before the fifth birthday. The most common causes of death among children under five were malaria (19%), respiratory infection (13%), and anemia (11%). The under-five mortality rate was 104.8 per 1,000 live births from 1999 to 2006 and 53.0 per 1,000 after the founding of the Lwala Community Alliance in 2007. Factors associated with under-five mortality included year of birth (HR 0.931; 95% CI: 0.877, 0.988; p = 0.019), multiple-gestation pregnancy (HR 6.201; 95% CI: 2.073, 18.555; p < 0.001), and birth in the long rain season (HR 1.981; 95% CI: 1.350, 2.907; p < 0.001). Birth spacing greater than 18 months was negatively associated with under-five mortality (HR 0.345; 95% CI: 0.203, 0.587; p < 0.001)., Conclusions: There was a significant decrease in under-five mortality before and after the presence of the Lwala Community Alliance. Multiple-gestation pregnancies, birth season, and short birth spacing were associated with under-five mortality and provide possible targets to further reduce mortality in the region. This provides both hyper-local data necessary for implementation efforts and generalizable data and sampling methods that may be useful for other implementing organizations in sub-Saharan Africa., Competing Interests: The authors have declared that no competing interests exist. Authors JS, LC, SS, MO, VO, and WE were previously or are currently employees of the Lwala Community Alliance. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Background and Objective: India contributes the highest global share of deaths among the under-fives. Continuous monitoring of the reduction in the under-five mortality rate (U5MR) at local level is thus essential to set priorities for policy-makers and health professionals. In this study, we aimed to provide an update on district-level disparities in the neonatal mortality rate (NMR) and the U5MR with special reference to Sustainable Development Goal 3 (SDG3) on preventable deaths among new-borns and children under five., Data and Methods: We used recently released population-based cross-sectional data from the National Family Health Survey (NFHS) conducted in 2015-2016. We used the synthetic cohort probability approach to analyze the full birth history information of women aged 15-49 to estimate the NMR and U5MR for the ten years preceding the survey., Results: Both the NMR and U5MR vary enormously across Indian districts. With respect to the SDG3 target for 2030 for the NMR and the U5MR, the estimated NMR for India for the period studied is about 2.4 times higher, while the estimated U5MR is about double. At district level, while 9% of the districts have already reached the NMR targeted in SDG3, nearly half (315 districts) are not likely to achieve the 2030 target even if they realize the NMR reductions achieved by their own states between the last two rounds of National Family Health Survey of India. Similarly, less than one-third of the districts (177) of India are unlikely to achieve the SDG3 target on the U5MR by 2030. While the majority of high-risk districts for the NMR and U5MR are located in the poorer states of north-central and eastern India, a few high-risk districts for NMR also fall in the rich and advanced states. About 97% of districts from Chhattisgarh and Uttar Pradesh, for example, are unlikely to meet the SDG3 target for preventable deaths among new-borns and children under age five, irrespective of gender., Conclusions: To achieve the SDG3 target on preventable deaths by 2030, the majority of Indian districts clearly need to make a giant leap to reduce their NMR and U5MR., Competing Interests: The authors have declared that no competing interests exist.

Although research on the fertility response to childhood mortality is widespread in demographic literature, very few studies focused on the two-way causal relationships between infant mortality and fertility. Understanding the nature of such relationships is important in order to design effective policies to reduce child mortality and improve family planning. In this study, we use dynamic panel data techniques to analyse the causal effects of infant mortality on birth intervals and fertility, as well as the causal effects of birth intervals on mortality in rural Bangladesh, accounting for unobserved heterogeneity and reverse causality. Simulations based upon the estimated model show whether (and to what extent) mortality and fertility can be reduced by breaking the causal links between short birth intervals and infant mortality. We find a replacement effect of infant mortality on total fertility of about 0.54 children for each infant death in the comparison area with standard health services. Eliminating the replacement effect would lengthen birth intervals and reduce the total number of births, resulting in a fall in mortality by 2.45 children per 1000 live births. These effects are much smaller in the treatment area with extensive health services and information on family planning, where infant mortality is smaller, birth intervals are longer, and total fertility is lower. In both areas, we find evidence of boy preference in family planning.

Background: Inhalation of secondhand smoke from tobacco results in serious health outcomes among under-five children, and yet, few studies have assessed its effect on under-five mortality. We investigated the association between frequency of exposure to household tobacco smoke and risk of under-five mortality in sub-Saharan Africa (SSA)., Methods: Demographic Health Survey data of under-five children from 23 SSA countries (n = 787,484) were used. Cox proportional hazard models described the association between exposure to tobacco smoke and the risk of under-five mortality in each country, with age as the time-to-event indicator. Meta-analysis was used to investigate the overall effect of tobacco smoke in SSA., Results: The association between tobacco smoke exposure and the risk of under-five mortality attenuated in eight countries (Burkina Faso, Benin, Congo, Gabon, Guinea, Liberia, Togo, and Zambia) after adjustment, while the hazard ratios (HR) of daily exposure to tobacco smoke in Kenya (HR = 1.40; 95% CI, 1.16-1.70) and Namibia (HR = 1.40; 1.07-1.83) grew. The children in rural areas in SSA were 1.08 (95% CI, 1.04-1.13) times more likely to die than their urban peers. In general, the exposure to household tobacco smoke was associated with an increased risk of under-five mortality in SSA (HR = 1.09; 95% CI, 1.06-1.13)., Conclusions: This study provided evidence of a positive association between exposure to household tobacco smoke and risk of under-five mortality in SSA. Policymakers in low- and middle-income countries, where tobacco control as a child health issue is relatively neglected, should integrate tobacco control measures with other child health promotion policies.

Introduction: Nigeria has one of the highest maternal mortality ratios in the world as well as high perinatal mortality. Unfortunately, the country does not have the resources to assess this critical indicator with the conventional health information system and measuring its progress toward the goal of ending preventable maternal deaths is almost impossible. Médecins Sans Frontières (MSF) conducted a cross-sectional study to assess maternal and perinatal mortality in Makoko Riverine and Badia East, two of the most vulnerable slums of Lagos., Materials and Methods: The study was a cross-sectional, community-based household survey. Nearly 4,000 households were surveyed. The sisterhood method was utilized to estimate maternal mortality and the preceding births technique was used to estimate newborn and child mortality. Questions regarding health seeking behavior were posed to female interviewees and self-reported data were collected., Results: Data was collected from 3963 respondents for a total of 7018 sisters ever married. The maternal mortality ratio was calculated at 1,050/100,000 live births (95% CI: 894-1215), and the lifetime risk of maternal death at 1:18. The neonatal mortality rate was extracted from 1967 pregnancies reported and was estimated at 28.4/1,000; infant mortality at 43.8/1,000 and under-five mortality at 103/1,000. Living in Badia, giving birth at home and belonging to the Egun ethnic group were associated with higher perinatal mortality. Half of the last pregnancies were reportedly delivered in private health facilities. Proximity to home was the main influencing factor (32.4%) associated with delivery at the health facility., Discussion: The maternal mortality ratio found in these urban slum populations within Lagos is extremely high, compared to the figure estimated for Lagos State of 545 per 100,000 live births. Urgent attention is required to address these neglected and vulnerable neighborhoods. Efforts should be invested in obtaining data from poor, marginalized, and hard-to-reach populations in order to identify pockets of marginalization needing additional resources and tailored approaches to guarantee equitable treatment and timely access to quality health services for vulnerable groups. This study demonstrates the importance of sub-regional, disaggregated data to identify and redress inequities that exist among poor, remote, vulnerable populations-as in the urban slums of Lagos.

Background: The death of a mother is a tragedy in itself but it can also have devastating effects for the survival of her children. We aim to explore the impact of a mother's death on child survival in rural Gambia, West Africa., Methods: We used 25 years of prospective surveillance data from the Farafenni Health and Demographic surveillance system (FHDSS). Mortality rates per 1,000 child-years up to ten years of age were estimated and Kaplan-Meier survival curves plotted by maternal vital status. Cox proportional hazard models were used to examine factors associated with child survival., Findings: Between 1st April 1989 and 31st December 2014, a total of 2, 221 (7.8%) deaths occurred during 152,906 child-years of follow up. Overall mortality rate was 14.53 per 1,000 child-years (95% CI: 13.93-15.14). Amongst those whose mother died, the rate was 25.89 (95% CI: 17.99-37.25) compared to 14.44 (95% CI: 13.84-15.06) per 1,000 child-years for those whose mother did not die. Children were 4.66 (95% CI: 3.15-6.89) times more likely to die if their mother died compared to those with a surviving mother. Infants whose mothers died during delivery or shortly after were up to 7 times more likely to die within the first month of life compared to those whose mothers survived. Maternal vital status was significantly associated with the risk of dying within the first 2 years of life (p-value <0.05), while this was no longer observed for children over 2 years of age (P = 0.872). Other factors associated with an increased risk of dying were living in more rural areas, and birth spacing and year of birth., Conclusions: Mother's survival is strongly associated with child survival. Our findings highlight the importance of the continuum of care for both the mother and child not only throughout pregnancy, and childbirth but beyond 6 weeks post-partum.

It has been hypothesised that facial traits such as masculinity and a healthy appearance may indicate heritable qualities in males (e.g. immunocompetence) and that, consequently, female preferences for such traits may function to increase offspring viability and health. However, the putative link between paternal facial features and offspring health has not previously been tested empirically in humans. Here we present data from two traditional societies with little or no access to modern medicine and family planning technologies. Data on offspring number and offspring survival were analysed for the Agta of the Philippines and the Maya of Belize, and archive facial photographs were assessed by observers for attractiveness and masculinity. While there was no association between attractiveness and offspring survival in either population, a quadratic relationship was observed between masculinity and offspring survival in both populations, such that intermediate levels of masculinity were associated with the lowest offspring mortality, with both high and low levels of masculinity being associated with increased mortality. Neither attractiveness nor masculinity were related to fertility (offspring number) in either population. We consider how these data may or may not reconcile with current theories of female preferences for masculinity in male faces and argue that further research and replication in other traditional societies should be a key priority for the field., Competing Interests: The authors have declared that no competing interests exist.

Objective: The literature on the impact of internal migration on under-five mortality in sub-Saharan Africa has been limited. This study examined the impact of internal migration on under-five mortality rate in 27 sub-Saharan African countries., Design: The analysis used cross-sectional data from the most recent Demographic and Health Surveys of 27 sub-Saharan African countries. Information on the number of live births and the number of under-five deaths in the five years preceding the surveys in these countries was examined. Using variables from which migration data were generated, four migration statuses were computed, and the impact of each migration status on under-five mortality was analysed by using multivariate Cox proportional hazards regression models., Results: Of the 96333 live births, 7036 deaths were reported. In the unadjusted model, we found that, compared to urban non-migrant mothers, hazard of under-five mortality was 20% [HR: 1.20; 95% confidence interval (CI): (1.06–1.35)], 40% [HR: 1.40; 95% CI: (1.29–1.53)], and 43% [HR: 1.43; 95% CI: (1.30–1.58)] higher among urban-rural migrant, rural non-migrant, and rural-urban migrant mothers respectively. The likelihood of children dying did not change considerably when country and demographic variables were adjusted for. However, after controlling for health care service utilization factors, the results remained consistently significant for rurality. That is, mortality rates remained significantly higher among children of rural non-migrant [(HR: 1.20; 95% CI: (1.08–1.33), P-value (p) < 0.001] and rural-urban migrant [HR: 1.29; 95% CI: (1.15–1.45), p < 0.001] mothers than those of urban non-migrant mothers., Conclusion: Although under-five child mortality rate declined by 52% between 1990 and 2015 (from 179 to 86 per1000 live births) in sub-Saharan Africa, the continent still has the highest rate in the world. This finding highlights the need to consider providing education and health care services in rural areas, when implementing interventions meant to reduce under-five mortality rates among internal migrant mothers., Competing Interests: The authors have declared that no competing interests exist.

Objectives: Under the prevailing conditions of imbalanced life table and historic gender discrimination in India, our study examines crossover between life expectancies at ages zero, one and five years for India and quantifies the relative share of infant and under-five mortality towards this crossover., Methods: We estimate threshold levels of infant and under-five mortality required for crossover using age specific death rates during 1981-2009 for 16 Indian states by sex (comprising of India's 90% population in 2011). Kitagawa decomposition equations were used to analyse relative share of infant and under-five mortality towards crossover., Findings: India experienced crossover between life expectancies at ages zero and five in 2004 for menand in 2009 for women; eleven and nine Indian states have experienced this crossover for men and women, respectively. Men usually experienced crossover four years earlier than the women. Improvements in mortality below ages five have mostly contributed towards this crossover. Life expectancy at age one exceeds that at age zero for both men and women in India except for Kerala (the only state to experience this crossover in 2000 for men and 1999 for women)., Conclusions: For India, using life expectancy at age zero and under-five mortality rate together may be more meaningful to measure overall health of its people until the crossover. Delayed crossover for women, despite higher life expectancy at birth than for men reiterates that Indian women are still disadvantaged and hence use of life expectancies at ages zero, one and five become important for India. Greater programmatic efforts to control leading causes of death during the first month and 1-59 months in high child mortality areas can help India to attain this crossover early.

Background: Most low- and middle-income countries lack fully functional civil registration systems. Measures of under-five mortality are typically derived from periodic household surveys collecting detailed information from women on births and child deaths. However, such surveys are expensive and are not appropriate for monitoring short-term changes in child mortality. We explored and tested the validity of two new analysis methods for less-expensive summary histories of births and child deaths for such monitoring in five African countries., Methods and Findings: The first method we explored uses individual-level survey data on births and child deaths to impute full birth histories from an earlier survey onto summary histories from a more recent survey. The second method uses cohort changes between two surveys in the average number of children born and the number of children dead by single year of age to estimate under-five mortality for the inter-survey period. The first method produces acceptable annual estimates of under-five mortality for two out of six applications to available data sets; the second method produced an acceptable estimate in only one of five applications, though none of the applications used ideal data sets., Conclusions: The methods we tested were not able to produce consistently good quality estimates of annual under-five mortality from summary birth history data. The key problem we identified was not with the methods themselves, but with the underlying quality of the summary birth histories. If summary birth histories are to be included in general household surveys, considerable emphasis must be placed on quality control.

Background: Health-related within-country inequalities continue to be a matter of great interest and concern to both policy makers and researchers. This study aims to assess the level and the distribution of child mortality outcomes in the Philippines across geographical and socioeconomic indicators., Methodology: Data on 159,130 children ever borne were analysed from five waves of the Philippine Demographic and Health Survey. Direct estimation was used to construct under-five and neonatal mortality rates for the period 1980-2013. Rate differences and ratios, and where possible, slope and relative indices of inequality were calculated to measure disparities on absolute and relative scales. Stratification was undertaken by levels of rural/urban location, island groups and household wealth., Findings: National under-five and neonatal mortality rates have shown considerable albeit differential reductions since 1980. Recently released data suggests that neonatal mortality has declined following a period of stagnation. Declines in under-five mortality have been accompanied by decreases in wealth and geography-related absolute inequalities. However, relative inequalities for the same markers have remained stable over time. For neonates, mixed evidence suggests that absolute and relative inequalities have remained stable or may have risen., Conclusion: In addition to continued reductions in under-five mortality, new data suggests that the Philippines have achieved success in addressing the commonly observed stagnated trend in neonatal mortality. This success has been driven by economic improvement since 2006 as well as efforts to implement a nationwide universal health care campaign. Yet, such patterns, nonetheless, accorded with persistent inequalities, particularly on a relative scale. A continued focus on addressing universal coverage, the influence of decentralisation and armed conflict, and issues along the continuum of care is advocated.

This paper extends Alexandr Chayanov's model of changing household demography (specifically the ratio of food consumers to food producers) and its influence on agricultural behavior so that it includes possible adverse effects of a rising ratio on nutritional status and early childhood mortality within the household. We apply the model to 35 years' worth of longitudinal demographic and economic data collected in the irrigated-rice growing village of Na Savang in northern Laos. When appropriate controls are included for other household variables, unobserved inter-household heterogeneity, and changes in local conditions and national policy over the study period, the analysis suggests that a unit increase in the household's consumer/producer ratio induces something like a nine-fold increase in the risk of death among household members aged less than five years. Monte Carlo simulation studies suggest that this may be an over-estimate but also that the effect is probably real and likely to be an important factor in household demography. At the very least, the results suggest that Chayanov's model still has theoretical relevance and deserves to be revived.

Background: Inpatient case fatality from severe malaria remains high in much of sub-Saharan Africa. The majority of these deaths occur within 24 hours of admission, suggesting that pre-hospital management may have an impact on the risk of case fatality., Methods: Prospective cohort study, including questionnaire about pre-hospital treatment, of all 437 patients admitted with severe febrile illness (presumed to be severe malaria) to the paediatric ward in Sikasso Regional Hospital, Mali, in a two-month period., Findings: The case fatality rate was 17.4%. Coma, hypoglycaemia and respiratory distress at admission were associated with significantly higher mortality. In multiple logistic regression models and in a survival analysis to examine pre-admission risk factors for case fatality, the only consistent and significant risk factor was sex. Girls were twice as likely to die as boys (AOR 2.00, 95% CI 1.08-3.70). There was a wide variety of pre-hospital treatments used, both modern and traditional. None had a consistent impact on the risk of death across different analyses. Reported use of traditional treatments was not associated with post-admission outcome., Interpretation: Aside from well-recognised markers of severity, the main risk factor for death in this study was female sex, but this study cannot determine the reason why. Differences in pre-hospital treatments were not associated with case fatality.

Background: Considerable improvements in life expectancy and other human development indicators in Indonesia are thought to mask considerable disparities between populations in the country. We examine the existence and extent of these disparities by measuring trends and inequalities in the under-five mortality rate and neonatal mortality rate across wealth, education and geography., Methodology: Using data from seven waves of the Indonesian Demographic and Health Surveys, direct estimates of under-five and neonatal mortality rates were generated for 1980-2011. Absolute and relative inequalities were measured by rate differences and ratios, and where possible, slope and relative indices of inequality. Disparities were assessed by levels of rural/urban location, island groups, maternal education and household wealth., Findings: Declines in national rates of under-five and neonatal mortality have accorded with reductions of absolute inequalities in clusters stratified by wealth, maternal education and rural/urban location. Across these groups, relative inequalities have generally stabilised, with possible increases with respect to mortality across wealth subpopulations. Both relative and absolute inequalities in rates of under-five and neonatal mortality stratified by island divisions have widened., Conclusion: Indonesia has made considerable gains in reducing under-five and neonatal mortality at a national level, with the largest reductions happening before the Asian financial crisis (1997-98) and decentralisation (2000). Hasty implementation of decentralisation reforms may have contributed to a slowdown in mortality rate reduction thereafter. Widening inequities between the most developed provinces of Java-Bali and those of other island groupings should be of particular concern for a country embarking on an ambitious plan for universal health coverage by 2019. A focus on addressing the key supply side barriers to accessing health care and on the social determinants of health in remote and disadvantaged regions will be essential for this plan to be realised.

Background: This paper examines if, when controlling for biophysical and geographical variables (including rainfall, productivity of agricultural lands, topography/temperature, and market access through road networks), socioeconomic and health care indicators help to explain variations in the under-five mortality rate across districts from nine high focus states in India. The literature on this subject is inconclusive because the survey data, upon which most studies of child mortality rely, rarely include variables that measure these factors. This paper introduces these variables into an analysis of 284 districts from nine high focus states in India., Methodology/principal Findings: Information on the mortality indicator was accessed from the recently conducted Annual Health Survey of 2011 and other socioeconomic and geographic variables from Census 2011, District Level Household and Facility Survey (2007-08), Department of Economics and Statistics Divisions of the concerned states. Displaying high spatial dependence (spatial autocorrelation) in the mortality indicator (outcome variable) and its possible predictors used in the analysis, the paper uses the Spatial-Error Model in an effort to negate or reduce the spatial dependence in model parameters. The results evince that the coverage gap index (a mixed indicator of district wise coverage of reproductive and child health services), female literacy, urbanization, economic status, the number of newborn care provided in Primary Health Centers in the district transpired as significant correlates of under-five mortality in the nine high focus states in India. The study identifies three clusters with high under-five mortality rate including 30 districts, and advocates urgent attention., Conclusion: Even after controlling the possible biophysical and geographical variables, the study reveals that the health program initiatives have a major role to play in reducing under-five mortality rate in the high focus states in India.

Background: The prevalence of Short Birth Interval (SBI) is higher in Low- and Middle-Income countries (LMICs), including Bangladesh. Previous studies in LMICs have estimated the effects of SBI on child mortality by comparing two unequal groups of mothers based on their socio-economic status. This approach may lead to overestimation or underestimation of the true effect of birth interval on child mortality, particularly when sample sizes are relatively small. Objective: We determined the effects of SBI on several forms of child mortality in Bangladesh by comparing two equal groups created by applying the propensity score matching technique. Methods: This study analyzed data from 5,941 mothers and 1,594 health facilities extracted from the 2017/18 Bangladesh Demographic and Health Survey and the 2017 Bangladesh Health Facility Survey. The exposure variable was SBI (defined as the interval between two subsequent births <33 months: yes, no), while the outcome variables were neonatal mortality (defined as mortality within 28 days of birth: yes, no), infant mortality (defined as mortality within 1 year of birth: yes, no), and under-five mortality (defined as mortality within 5 years of birth: yes, no). Multilevel Poisson regression based on inverse probability treatment weights was used to determine the association between exposure and outcome variables. Results: The prevalence rates of neonatal, infant, and under-five mortality were 48.8, 30.8, and 23.1 per 1000 live births, respectively. Newborns of SBI mothers were found to have a 63% higher likelihood of neonatal mortality (aPR, 1.63; 95% CI, 1.08–2.46) compared to newborns of non-SBI mothers. Furthermore, the prevalence of infant mortality and under-five mortality was 1.45 times higher (aPR, 1.45; 95% CI, 1.01–2.08) and 2.82 times higher (aPR, 2.82; 95% CI, 2.16–3.70), respectively, among babies born in a short interval of their immediately preceding sibling as compared to babies born in a normal interval of their immediately preceding sibling. Conclusions: Findings of this study indicate that SBI is an important predictor of child mortality. Consequently, around 1 million children born in a short interval every year in Bangladesh are at risk of dying before reaching their fifth birthday. This indicates a challenge for Bangladesh to achieve the SDG 3 target to reduce neonatal and under-five mortality to 12 and 25 deaths per 1000 live births, respectively. Hence, awareness-building programs about the adverse effects of SBI and strengthening existing healthcare facilities are important. [ABSTRACT FROM AUTHOR]

Background: Skilled birth attendants (SBAs) play a crucial role in reducing infant and maternal mortality. Although the ratio of skilled assistance at birth has increased in Bangladesh, factors associated with SBA use are unknown. The main goal of our study was to reveal the individual- and community-level factors associated with SBA use during childbirth in Bangladesh. We also showed the prevalence and trend of SBA use and related independent variables in Bangladesh over the past decade. Methods: This study utilized the Bangladesh Health and Demographic Survey (BDHS) 2017–2018, a cross-sectional study. We used binary logistic regression to examine the extent of variation in SBA use attributable to the individual- and community-level variables. Results: Overall, 53.35% of women received assistance from SBAs during childbirth. The average annual rate of increase (AARI) in the number of SBA-assisted births over the past 10 years was 8.88%. Respondents who gave birth at or above 19 years had 1.40 times (AOR = 1.40; 95% CI: 1.21–1.62) greater odds of having skilled delivery assistance than respondents aged 18 years old or less. Women and their husband's education levels were significantly associated with using skilled assistance during delivery, with odds of 1.60 (AOR = 1.60; 95% CI: 1.45–2.01) and 1.41 (AOR = 1.41; 95% CI: 1.21–1.66), respectively compared to those with education up to primary level. Women from rich families and those receiving better antenatal care (ANC) visits were more likely to have professional delivery assistance. Community-level factors also showed significance towards having professional assistance while giving birth. Women from urban communities and those who utilized more than four ANC visits and had completed secondary or higher education showed a greater tendency to use an SBA during childbirth than their counterparts. Conclusion: The use of SBAs during delivery was significantly associated with some individual- and community-level factors. To reduce maternal and child mortality, there is a need to focus on rural and uneducated people who are less likely to access these facilities. Special programs could increase awareness and help the poor community obtain the minimum facility in maternal care. [ABSTRACT FROM AUTHOR]

Background: Previous research on the association between maternal HIV status and child mortality in sub–Saharan Africa was published between 2005–2011. Findings from these studies showed a higher child mortality risk among children born to HIV–positive mothers. While the population of women with disabilities is growing in developing countries, we found no research that examined the association between maternal disability in HIV–positive mothers, and child mortality in sub–Saharan Africa. This study examined the potential compounding effect of maternal disability and HIV status on child mortality in South Africa. Methods: We analyzed data for women age 15–49 years from South Africa, using the nationally representative 2016 South Africa Demographic and Health Survey. We estimated unadjusted and adjusted risk ratios of child mortality indicators by maternal disability and maternal HIV using modified Poisson regressions. Results: Children born to disabled mothers compared to their peers born to non-disabled mothers were at a higher risk for neonatal mortality (RR = 1.80, 95% CI:1.31–2.49), infant mortality (RR = 1.69, 95% CI:1.19–2.41), and under-five mortality (RR = 1.78, 95% CI:1.05–3.01). The joint risk of maternal disability and HIV-positive status on the selected child mortality indicators is compounded such that it is more than the sum of the risks from maternal disability or maternal HIV-positive status alone (RR = 3.97 vs. joint RR = 3.67 for neonatal mortality; RR = 3.57 vs. joint RR = 3.25 for infant mortality; RR = 6.44 vs. joint RR = 3.75 for under-five mortality). Conclusions: The findings suggest that children born to HIV-positive women with disabilities are at an exceptionally high risk of premature mortality. Established inequalities faced by women with disabilities may account for this increased risk. Given that maternal HIV and disability amplify each other's impact on child mortality, addressing disabled women's HIV-related needs and understanding the pathways and mechanisms contributing to these disparities is crucial. [ABSTRACT FROM AUTHOR]

Infant and maternal mortality are important indicators for assessing the quality of healthcare systems. The World Health Organization underscores the importance of proper health care system in reducing preventable mortality through early intervention. Early intervention includes availability, accessibility and affordability of health care systems for children and mothers. While there are several studies that assess the immediate and underlying drivers of child mortality, literature on the role of policy measures are limited and inconsistent. Thus, robust empirical analysis of the determinants of maternal and infant mortality remains inconclusive in the era of achieving the Sustainable Development Goals (SDG). Here, we examined the influence of health expenditure on infant and maternal deaths for the period 2000–2015 across 177 countries. Using panel Quantile Regression with bootstrapping, this study accounted for the 2007–2008 financial crisis in an empirical relationship between health outcome and health expenditure. We found a negative effect of health expenditure on mortality across all percentiles. Infant mortality rate declines between 0.19% - 1.45% while maternal mortality rate declines ranging from 0.09% - 1.91%. To attain the goal of ensuring healthy lives and wellbeing of all people (SDG 3), this study infers that health expenditure potentially reduces maternal and infant mortality across lower and middle income countries. We highlight the need for an enhanced health care expenditure, especially in developing countries to curb the levels of infant and maternal deaths. [ABSTRACT FROM AUTHOR]

Background: Humans life histories have been described as "slow", patterned by slow growth, delayed maturity, and long life span. While it is known that human life history diverged from that of a recent common chimpanzee-human ancestor some ~4–8 mya, it is unclear how selection pressures led to these distinct traits. To provide insight, we compare wild chimpanzees and human subsistence societies in order to identify the age-specific vital rates that best explain fitness variation, selection pressures and species divergence. Methods: We employ Life Table Response Experiments to quantify vital rate contributions to population growth rate differences. Although widespread in ecology, these methods have not been applied to human populations or to inform differences between humans and chimpanzees. We also estimate correlations between vital rate elasticities and life history traits to investigate differences in selection pressures and test several predictions based on life history theory. Results: Chimpanzees' earlier maturity and higher adult mortality drive species differences in population growth, whereas infant mortality and fertility variation explain differences between human populations. Human fitness is decoupled from longevity by postreproductive survival, while chimpanzees forfeit higher potential lifetime fertility due to adult mortality attrition. Infant survival is often lower among humans, but lost fitness is recouped via short birth spacing and high peak fertility, thereby reducing selection on infant survival. Lastly, longevity and delayed maturity reduce selection on child survival, but among humans, recruitment selection is unexpectedly highest in longer-lived populations, which are also faster-growing due to high fertility. Conclusion: Humans differ from chimpanzees more because of delayed maturity and lower adult mortality than from differences in juvenile mortality or fertility. In both species, high child mortality reflects bet-hedging costs of quality/quantity tradeoffs borne by offspring, with high and variable child mortality likely regulating human population growth over evolutionary history. Positive correlations between survival and fertility among human subsistence populations leads to selection pressures in human subsistence societies that differ from those in modern populations undergoing demographic transition. [ABSTRACT FROM AUTHOR]

Background: Malnutrition and low birth weight (LBW) are two common causes of morbidity and mortality among children in sub-Saharan Africa. Both malnutrition and LBW affect early childhood development with long term consequences that may vary in their degree depending on the geographical setting. This study evaluates growth, nutritional status and mortality of infants from Lambaréné and Fougamou in Gabon from a birth cohort of a malaria in pregnancy clinical trial (NCT00811421). Method: A prospective longitudinal birth cohort conducted between 2009 and 2012, included infants that were followed up from birth until their first-year anniversary. The exposure of interest was low birth weight and the outcomes explored were growth represented by weight gain, the nutritional status including stunting, wasting and underweight, and the mortality. Scheduled follow-up visits were at one, nine and 12 months of age. Logistic regression was used to assess the association between low birth weight and growth and nutritional outcomes, and cox regression was used for mortality. Result: A total of 907 live-born infants were included in the analysis. The prevalence of LBW was 13% (115). At one month of life, out of 743 infants 10% and 4% presented with stunting and underweight, respectively, while these proportions increased at 12 months of life to 17% and 21%, respectively, out of 530 infants. The proportion of infants with wasting remained constant at 7% throughout the follow-up period. Stunting and underweight were associated with LBW, adjusted odds ratio (aOR): 2.6, 95% confidence interval (95%CI): 1.4–4.9 and aOR: 4.5, 95%CI: 2.5–8.1, respectively. Preterm birth was associated with stunting, aOR: 2.7, 95%CI: 1.2–6.3 and underweight, aOR: 5.4, 95%CI: 1.7–16.1 at one month of life. Infants with LBW were at higher hazard of death during the first year of life, adjusted hazard ratio 4.6, 95%CI: 1.2–17.0. Conclusion: Low birthweight infants in Gabon are at higher risks of growth and nutritional deficits and mortality during the first year of life. Tailored interventions aiming at preventing adverse pregnancy outcomes including LBW, early detection and appropriate management of growth, and nutritional deficits in infants are necessary in Gabon. [ABSTRACT FROM AUTHOR]

Introduction: Within country inequality in infant mortality poses a big challenge for countries moving towards the internationally agreed upon targets on child mortality by 2030. There is a lack of high-quality evidence on infant mortality measured through different dimensions of social inequality in Angola. Thus, this paper was carried out to address the knowledge gap by conducting in-depth examination of infant mortality rate (IMR) inequality among population subgroups to provide more nuanced evidence to help end IMR disparity in the country. Methods: The World Health Organization's (WHO) Health Equity Assessment Toolkit (HEAT) was used to analyze IMR inequality. HEAT is a software application that facilitates examination of disparities in reproductive, maternal, neonatal and child health indicators using the WHO Health Equity Monitor (HEM) database. Inequality of IMR was analyzed through disaggregation by five equity stratifiers: education, wealth, gender, subnational region and residence. These were analyzed through three inequality measures: Population Attributable Risk, Ratio and Slope Index of Inequality. A 95% confidence Interval (CI) was built around point estimates to determine statistical significance. Results: A notable disadvantage was found for children born to poor (Population Attributable Risk (PAR): -27.0; -28.4, -26.0) and uneducated (PAR: -17.0; -17.9, -16.0), women who live in rural areas (PAR: -7.3;-7.8, -6.7) and those residing in certain regions of the country (PAR: -43.0; 45.3, -4). Male infants had a higher risk of death than female infants (PAR: -6.8;-7.5, -6.2). The subnational regional variation of IMR had been the most evident when compared with the disparities in the other equity stratifers. Conclusions: Policymakers and planners need to address the disproportionately higher clustering of IMR among infants born to disadvantaged subpopulations through interventions that benefit such subgroups. [ABSTRACT FROM AUTHOR]

Background: Child health has been a health policy priority for more than a century in Chile. Since 2000, new health and intersectoral interventions have been implemented. However, no recent analyses have explored child mortality and equity in Chile, an indispensable input to guide policies towards the achievement of the Sustainable Development Goals, specially, in the context of a deeply unequal country such as many other Latin American countries. Thus, the objectives of this study are to analyze the variations in the risk and the causes of death among Chilean children aged <5 years, to identify the determinants, and to measure inequality of infant mortality from 1990 to 2016. Materials and methods: An observational study was conducted to analyze the Chilean children's mortality from 1990 to 2016 using under five deaths and live births data from the Vital Statistics System. To describe the variation in the risk of death, a time series analysis was performed for each of the under five mortality rate components. A comparative cause of death analysis was developed for Neonatal and 1–59 months' age groups. The determinants of infant mortality were studied with a descriptive analysis of yearly rates according to mother's and child factors and bivariate logistic regression models at the individual level. Finally, simple and complex measures of inequality at individual level were estimated considering three-year periods. Results: Regarding under 5 mortality: (i) Child survival has improved substantially in the last three decades, with a rapid decline in under five mortality rate between 1990 and 2001, followed by a slower reduction; (ii) early neonatal mortality has become the main component of the under five mortality rate (50.6%); (iii) congenital abnormalities have positioned as the leading cause of death; (iv) an important increase in live births below 1,000 grs. Regarding infant mortality: (i) birth weight and gestational age are the two most relevant risk factors in the neonatal period, while social variables are more significant for post-neonatal mortality and, (ii) the inequality according to mother's education has shown a steady decline, with persistent inequalities in post-neonatal period. Conclusions: The Chilean experience illustrates child health achievements and challenges in a country that transitioned from middle-to high-income in recent decades. Although inequity is one of the main challenges for the country, the health sector by granting universal access was able to reduce disparities. However, closing the gap in post-neonatal mortality is still challenging. To overcome stagnation in neonatal mortality, new and specific strategies must address current priorities, emphasizing the access of vulnerable groups. [ABSTRACT FROM AUTHOR]

Objective: This study attempts to investigate the association between maternal exposure to intimate partner violence (IPV) and morbidity and mortality of children. Study design: A cross-sectional study was carried out using the most recent nationally representative data of the National Family Health Survey (NFHS-4) in India. Results: The prevalence of morbidity and mortality was higher among the children whose mothers faced physical, emotional, or sexual violence perpetrated by the partner than those who did not encounter any violence. Multivariate analysis revealed that maternal exposure to physical and sexual violence significantly increased the risks of childhood diarrhea and fever; and emotional violence was associated with an increased likelihood of diarrhea, fever, and acute respiratory infection (ARI) in the past 2 weeks among under-five children. Moreover, women's experience of physical and emotional violence were associated with increased odds of infant mortality (<1 year) and under-five mortality (<5 years) in crude analysis. However, these associations were insignificant in the adjusted analysis. Similarly, we did not find any significant association between maternal exposure to IPV and child mortality (1 to < 5 years). Conclusion: Maternal experience of domestic violence was associated with an increased risk of childhood morbidity (diarrhea, fever and ARI). However, no significant association was found between violence against women and mortality of children. Prevention of domestic violence may help to reduce childhood illnesses. Additional efforts are needed for maternal and child healthcare programs to improve health status of women and children. [ABSTRACT FROM AUTHOR]

Background: The Ghana Health Service in collaboration with partner institutions implemented a five-year primary health systems strengthening program known as the Ghana Essential Health Intervention Program (GEHIP). GEHIP was a plausibility trial implemented in an impoverished region of northern Ghana around the World Health Organizations (WHO) six pillars combined with community engagement, leadership development and grassroots political support, the program organized a program of training and action focused on strategies for saving newborn lives and community-engaged emergency referral services. This paper analyzes the effect of the GEHIP program on child survival. Methods: Birth history data assembled from baseline and endline surveys are used to assess the hazard of child mortality in GEHIP treatment and comparison areas prior to and after the start of treatment. Difference-in-differences (DiD) methods are used to compare mortality change over time among children exposed to GEHIP relative to children in the comparison area over the same time period. Models test the hypothesis that a package of systems strengthening activities improved childhood survival. Models adjusted for the potentially confounding effects of baseline differentials, secular mortality trends, household characteristics such as relative wealth and parental educational attainment, and geographic accessibility of clinical care. Results: The GEHIP combination of health systems strengthening activities reduced neonatal mortality by approximately one half (HR = 0.52, 95% CI = 0.28,0.98, p = 0.045). There was a null incremental effect of GEHIP on mortality of post-neonate infants (from 1 to 12 months old) (HR = 0.72; 95% CI = 0.30,1.79; p = 0.480) and post-infants (from 1 year to 5 years old) -(HR = 1.02; 95% CI = 0.55–1.90; p = 0.940). Age-specific analyses show that impact was concentrated among neonates. However, effect ratios for post-infancy were inefficiently assessed owing to extensive survival history censoring for the later months of childhood. Children were observed only rarely for periods over 40 months of age. Conclusion: GEHIP results show that a comprehensive approach to newborn care is feasible, if care is augmented by community-based nurses. It supports the assertion that if appropriate mechanisms are put in place to enable the various pillars of the health system as espoused by WHO in rural impoverished settings where childhood mortality is high, it could lead to accelerated reductions in mortality thereby increasing survival of children. Policy implications of the pronounced neonatal effect of GEHIP merit national review for possible scale-up. [ABSTRACT FROM AUTHOR]

The Demographic and Health Surveys (DHS) are a major source for many demographic and health indicators in developing countries. Although these indicators are well defined in the literature, using survey data to calculate some of these indicators has never been an easy task for data users. This paper presents the software, a user-friendly R package developed to calculate fertility indicators, such as the total fertility rate, general fertility rate, and age-specific fertility rates, and childhood mortality indicators, such as the neonatal mortality rate, post-neonatal mortality rate, infant mortality rate, child mortality rate, and under-5 mortality rate, from the DHS data. The package allows for national and subnational indicators. In addition, the package calculates sampling error indicators such as standard error, design effect, relative standard error, and confidence interval for each demographic indicator. The package can also be used to calculate the same indicators from other population surveys such as the Multiple Indicator Cluster Survey (MICS). [ABSTRACT FROM AUTHOR]

Introduction: Under-five mortality estimates are increasingly used in low and middle income countries to target interventions and measure performance against global development goals. Two new methods to rapidly estimate under-5 mortality based on Summary Birth Histories (SBH) were described in a previous paper and tested with data available. This analysis tests the methods using data appropriate to each method from 5 countries that lack vital registration systems. SBH data are collected across many countries through censuses and surveys, and indirect methods often rely upon their quality to estimate mortality rates. Methods and findings: The Birth History Imputation method imputes data from a recent Full Birth History (FBH) onto the birth, death and age distribution of the SBH to produce estimates based on the resulting distribution of child mortality. DHS FBHs and MICS SBHs are used for all five countries. In the implementation, 43 of 70 estimates are within 20% of validation estimates (61%). Mean Absolute Relative Error is 17.7.%. 1 of 7 countries produces acceptable estimates. The Cohort Change method considers the differences in births and deaths between repeated Summary Birth Histories at 1 or 2-year intervals to estimate the mortality rate in that period. SBHs are taken from Brazil’s PNAD Surveys 2004–2011 and validated against IGME estimates. 2 of 10 estimates are within 10% of validation estimates. Mean absolute relative error is greater than 100%. Conclusions: Appropriate testing of these new methods demonstrates that they do not produce sufficiently good estimates based on the data available. We conclude this is due to the poor quality of most SBH data included in the study. This has wider implications for the next round of censuses and future household surveys across many low- and middle- income countries. [ABSTRACT FROM AUTHOR]

Background: The rate of decline in child mortality is too slow in most African countries to achieve the Millennium Development Goal of reducing under-five mortality by two-thirds between 1990 and 2015. Effective strategies to monitor child mortality are needed where accurate vital registration data are lacking to help governments assess and report on progress in child survival. We present results from a test of a mortality monitoring approach based on recording of births and deaths by specially trained community health workers (CHWs) in Malawi. Methods and Findings: Government-employed community health workers in Malawi are responsible for maintaining a Village Health Register, in which they record births and deaths that occur in their catchment area. We expanded on this system to provide additional training, supervision and incentives. We tested the equivalence between child mortality rates obtained from data on births and deaths collected by 160 randomly-selected and trained CHWs over twenty months in two districts to those computed through a standard household mortality survey. CHW reports produced an under-five mortality rate that was 84% (95%CI: [0.71,1.00]) of the household survey mortality rate and statistically equivalent to it. However, CHW data consistently underestimated under-five mortality, with levels of under-estimation increasing over time. Under-five deaths were more likely to be missed than births. Neonatal and infant deaths were more likely to be missed than older deaths. Conclusion: This first test of the accuracy and completeness of vital events data reported by CHWs in Malawi as a strategy for monitoring child mortality shows promising results but underestimated child mortality and was not stable over the four periods assessed. Given the Malawi government's commitment to strengthen its vital registration system, we are working with the Ministry of Health to implement a revised version of the approach that provides increased support to CHWs. [ABSTRACT FROM AUTHOR]

Background: The policy to provide oral polio vaccine (OPV) at birth was introduced in low-income countries to increase coverage. The effect of OPV at birth on overall child mortality was never studied. During a trial of vitamin A supplementation (VAS) at birth in Guinea-Bissau, OPV was not available during several periods. We took advantage of this ''natural experiment'' to test the effect on mortality of receiving OPV at birth. Methodology: Between 2002 and 2004, the VAS trial randomised normal-birth-weight infants to 50,000 IU VAS or placebo administered with BCG. Provision of OPV at birth was not part of the trial, but we noted whether the infants received OPV or not. OPV was missing during several periods in 2004. We used Cox proportional hazards models to compute mortality rate ratios (MRR) of children who had received or not received OPV at birth. Principal Findings: A total of 962 (22.1%) of the 4345 enrolled children did not receive OPV at birth; 179 children died within the first year of life. Missing OPV at birth was associated with a tendency for decreased mortality (adjusted MRR = 0.69 (95% CI = 0.46-1.03)), the effect being similar among recipients of VAS and placebo. There was a highly significant interaction between OPV at birth and sex (p = 0.006). Not receiving OPV at birth was associated with a weak tendency for increased mortality in girls (1.14 (0.70-1.89)) but significantly decreased mortality in boys (0.35 (0.18-0.71)). Conclusions: In our study OPV at birth had a sex-differential effect on mortality. Poliovirus is almost eradicated and OPV at birth contributes little to herd immunity. A randomised study of the effect of OPV at birth on overall mortality in both sexes is warranted. [ABSTRACT FROM AUTHOR]