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An Analysis of Determinants of Under-5 Mortality across Countries: Defining Priorities to Achieve Targets in Sustainable Developmental Goals

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An Erratum to this article was published on 27 February 2017


Objectives The end of the era of millennium development goals (MDGs) ushered in the sustainable development goals (SDGs) with a new target for the reduction of under-five mortality rates (U5MR). Although U5MR decreased globally, the reduction was insufficient to meet MDGs targets because significant socioeconomic inequities remain unaddressed across and within countries. Thus, further progress in achieving the new SDGs target will be hindered if there is no adequate prioritization of important socioeconomic, healthcare, and environmental factors. The objective of this study was to assess factors that account most for the differences in U5MR between countries around the globe. Methods We conducted an ordinary least squares (OLS) regression-based prioritization analysis of socioeconomic, healthcare, and environmental variables from 109 countries to understand which factors explain the differences in U5MR best. Results All indicators examined individually affected differences in U5MR between countries. However, the results of multivariate OLS regression showed that the most important factors that accounted for the differences were, in order: fertility rate, total health expenditure per capita, access to improved water and sanitation, and female employment rate. Conclusions To achieve the new global target for U5MR, policymakers must focus on certain priority areas, such as interventions that address access to affordable maternal healthcare services, educational programs for mothers, especially those who are adolescents, and safe drinking water and sanitation.

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  • Aseweh Abor, P., Abekah-Nkrumah, G., Sakyi, K., Adjasi, C. K., & Abor, J. (2011). The socio-economic determinants of maternal health care utilization in Ghana. International Journal of Social Economics, 38(7), 628–648.

    Article  Google Scholar 

  • Bauze, A. E., Tran, L. N., Nguyen, K. H., Firth, S., Jimenez-Soto, E., Dwyer-Lindgren, L., & Lopez, A. D. (2012). Equity and geography: The case of child mortality in Papua New Guinea. PloS ONE, 7(5), doi:10.1371/journal.pone.0037861.

  • Bhutta, Z. A., Ahmed, T., Black, R. E., Cousens, S., Dewey, K., Giugliani, E., & Maternal and Child Undernutrition Study Group. (2008). What works? Interventions for maternal and child undernutrition and survival. Lancet, 371(9610), 417–440.

    Article  PubMed  Google Scholar 

  • Bicego, G. T., & Boerma, J. T. (1993). Maternal education and child survival: A comparative study of survey data from 17 countries. Social Science & Medicine, 36(9), 1207–1227.

    Article  CAS  Google Scholar 

  • Black, R. E., Cousens, S., Johnson, H. L., Lawn, J. E., Rudan, I., Bassani, D. G., & Child Health Epidemiology Reference Group of WHO and UNICEF. (2010). Global, regional, and national causes of child mortality in 2008: A systematic analysis. Lancet, 375(9730), 1969–1987.

    Article  PubMed  Google Scholar 

  • Breierova, L., & Duflo, E. (2004). The impact of education on fertility and child mortality: Do fathers really matter less than mothers? (No. w10513). National Bureau of Economic Research.

  • Caldwell, J. C. (1979). Education as a factor in mortality decline: An examination of Nigerian data. Population Studies, 3, 395–413.

    Article  Google Scholar 

  • Cheng, J. J., Schuster-Wallace, C. J., Watt, S., Newbold, B. K., & Mente, A. (2012). An ecological quantification of the relationships between water, sanitation, and infant, child, and maternal mortality. Environmental Health, 11(1), 1–8.

    Article  Google Scholar 

  • CIA. (2015). The world factbook.

  • Cleland, J. G., & Van Ginneken, J. K. (1988). Maternal education and child survival in developing countries: The search for pathways of influence. Social Science & Medicine, 27(12), 1357–1368.

    Article  CAS  Google Scholar 

  • Deloitte Center for Health Solutions. (2014). Dig deep: Impacts and implications of rising out-of-pocket health care costs.

  • Ettarh, R. R., & Kimani, J. (2012). Determinants of under-five mortality in rural and urban Kenya. Rural and Remote Health, 12(1812), 22417123.

    Google Scholar 

  • Feng, X. L., Theodoratou, E., Liu, L., Chan, K. Y., Hipgrave, D., Scherpbier, R., & Guo, Y. (2012). Social, economic, political and health system and program determinants of child mortality reduction in China between 1990 and 2006: A systematic analysis. Journal of Global Health, 2(1), 48–49.

    Google Scholar 

  • Filmer, D., & Pritchett, L. (1997). Child mortality and public spending on health: How much does money matter? ‎Washington, DC: World Bank Publications.

    Google Scholar 

  • Fink, G., Günther, I., & Hill, K. (2011). The effect of water and sanitation on child health: Evidence from the demographic and health surveys 1986–2007. International Journal of Epidemiology, 40(5), 1196–1204.

    Article  PubMed  Google Scholar 

  • Fox, J. (2015). Applied regression analysis and generalized linear models. Chicago: Sage.

    Google Scholar 

  • Gakidou, E., Cowling, K., Lozano, R., & Murray, C. J. (2010). Increased educational attainment and its effect on child mortality in 175 countries between 1970 and 2009: A systematic analysis. Lancet, 376(9745), 959–974.

    Article  PubMed  Google Scholar 

  • Günther, I., & Fink, G. (2011). Water and sanitation to reduce child mortality: The impact and cost of water and sanitation infrastructure. World bank policy research working paper series.

  • Harrell, F. E. Jr. (2015). Multivariate modeling strategies. In F. E. Harrell Jr. (Ed.), Regression modeling strategies (pp. 63–102). Nashville, TN: Springer.

    Chapter  Google Scholar 

  • Hobcraft, J. N., McDonald, J. W., & Rutstein, S. O. (1984). Socio-economic factors in infant and child mortality: A cross-national comparison. Population Studies, 38(2), 193–223.

    Article  CAS  PubMed  Google Scholar 

  • Houweling, T. A., Kunst, A. E., Looman, C. W., & Mackenbach, J. P. (2005). Determinants of under-5 mortality among the poor and the rich: A cross-national analysis of 43 developing countries. International Journal of Epidemiology, 34(6), 1257–1265. doi:10.1093/ije/dyi190.

    Article  PubMed  Google Scholar 

  • Kanmiki, E. W., Bawah, A. A., Agorinya, I., Achana, F. S., Awoonor-Williams, J. K., Oduro, A. R., & Akazili, J. (2014). Socio-economic and demographic determinants of under-five mortality in rural northern Ghana. BMC International Health and Human Rights, 14(1), 24.

    Article  PubMed  PubMed Central  Google Scholar 

  • Kimani-Murage, E. W., Fotso, J. C., Egondi, T., Abuya, B., Elungata, P., Ziraba, A. K. & Madise, N. (2014). Trends in childhood mortality in Kenya: The urban advantage has seemingly been wiped out. Health & Place, 29, 95–103.

    Article  CAS  Google Scholar 

  • LaLonde, S. M. (2005). Transforming variables for normality and linearity—When, how, why and why nots. In SAS conference proceedings NESUG (pp. 11–14).

  • Liu, L., Johnson, H. L., Cousens, S., Perin, J., Scott, S., Lawn, J. E., & Child Health Epidemiology Reference Group of WHO and UNICEF. (2012). Global, regional, and national causes of child mortality: An updated systematic analysis for 2010 with time trends since 2000. Lancet, 379(9832), 2151–2161.

    Article  PubMed  Google Scholar 

  • Macassa, G., Ghilagaber, G., Bernhardt, E., Diderichsen, F., & Burström, B. (2003). Inequalities in child mortality in Mozambique: Differentials by parental socio-economic position. Social Science & Medicine, 57(12), 2255–2264.

    Article  Google Scholar 

  • Moser, A. K., Leon, D. A, & Gwatkin, D. R. (2005). How does progress towards the child mortality millennium development goal affect inequalities between the poorest and least poor? Analysis of demographic and health survey data. BMJ, 331, 1180–1182. doi:10.1136/bmj.38659.588125.79.

    Article  PubMed  PubMed Central  Google Scholar 

  • Ortiz, J., McGilligan, K., & Kelly, P. (2004). Duration of breast milk expression among working mothers enrolled in an employer-sponsored lactation program. Pediatric Nursing, 3(2), 111–119.

    Google Scholar 

  • Rosicova, K., Geckova, A. M., van Dijk, J. P., Kollarova, J., Rosic, M., & Groothoff, J. W. (2011). Regional socioeconomic indicators and ethnicity as predictors of regional infant mortality rate in Slovakia. International Journal of Public Health, 56(5), 523–531.

    Article  PubMed  Google Scholar 

  • Rutstein, S. O., & Winter, R. (2014). The effects of fertility behavior on child survival and child nutritional status: Evidence from the Demographic and Health Surveys 2006 to 2012.

  • Ryan, A. S., Zhou, W., & Arensberg, M. B. (2006). The effect of employment status on breastfeeding in the United States. Women’s Health Issues, 16(5), 243–251.

    Article  PubMed  Google Scholar 

  • Schoeps, A., Souares, A., Niamba, L., Diboulo, E., Kynast-Wolf, G., Müller, O., & Becher, H. (2014). Childhood mortality and its association with household wealth in rural and semi-urban Burkina Faso. Transactions of the Royal Society of Tropical Medicine and Hygiene, 108, 639–647.

    Article  PubMed  Google Scholar 

  • Singh, L., Rai, R. K., & Singh, P. K. (2012). Assessing the utilization of maternal and child health care among married adolescent women: Evidence from India. Journal of Biosocial Science, 44(01), 1–26.

    Article  PubMed  Google Scholar 

  • The Commonwealth Fund. (2014). Too high a price: Out-of-pocket health care costs in the United States.

  • The World Bank Group. (2015). World development indicators.

  • United Nations Educational, Scientific, and Cultural Organization. (2015). Education: Literacy rate.

  • Urdinola, B. P., & Ospino, C. (2015). Long-term consequences of adolescent fertility: The Colombian case. Demographic Research, 32, 1487–1518.

    Article  Google Scholar 

  • Wang, L. (2003). Determinants of child mortality in LDCs: Empirical findings from demographic and health surveys. Health Policy, 65(3), 277–299.

    Article  PubMed  Google Scholar 

  • World Health Organization. (2014). Global health expenditure database.

  • World Health Organization. (2015). MDG 4: Reduce child mortality.

  • World Health Organization. (2015). Under-five mortality—Situation and trends.

  • World Health Organization. (2015). Child mortality indicators: Latest situation and change over time.

  • You, D., Wardlaw, T., Salama, P., & Jones, G. (2010). Levels and trends in under-5 mortality, 1990–2008. Lancet, 375(9709), 100–103.

    Article  PubMed  Google Scholar 

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Correspondence to Michael Acheampong.

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Appendix 1

See Table 7.

Table 7 Independent variables, assumptions for selection, and sources of data

Appendix 2

See Table 8.

Table 8 Total list of countries initially considered in the study

Appendix 3

Details of Statistics of Independent Variables (IVs)

The summary shows that the IVs varied significantly between countries in the study. As seen in the Table 9, the 2010 total fertility rate for all countries in the study ranged from 1.24 children per woman in Bosnia and Herzegovina to 7.58 children per woman in Niger. Adolescent fertility rate also was reported to range significantly between countries; the Republic of Korea had the lowest adolescent fertility rate in 2010, with 1.92 births per 1000 adolescent women, while Niger recorded the highest with 210.37 births. With respect to total adult literacy rate, Guinea recorded the lowest (25.31%), and the highest (100%) was reported in both France and Norway. Female adult literacy displayed a pattern similar to that of total adult literacy. The lowest was recorded in Guinea (12.19%), while the highest was recorded in both France and Norway (100%).

With respect to percent rural population, a wide range can be observed in the table, from 2.36% recorded in Belgium to 89.36% in Burundi. GNI per capita was another variable that differed significantly between countries examined in the study, ranging from $560 in the Democratic Republic of Congo to $59,400 in Norway. The table also shows that the 2010 total female employment to population ratio in all countries in the study ranged from a low of 10.2% in Syria to a high of 86.4% in Rwanda. With respect to the percentage of the population living beneath the national poverty line, the United Arab Emirates recorded the lowest (0%), while Equatorial Guinea had the highest (76.8%).

Government expenditure on health as a percent of total health expenditure ranged from 1.59% in Afghanistan to 22.35% in the United States. Per capita total expenditure on health also ranged from $11.90 in Eritrea to $8361.73 in the United States. The table also shows out-of-pocket expenditure as a percent of total health expenditure, which ranged from 5.2% in the Netherlands to 88.15% in Guinea.

The final part of the table summarizes the statistics for the two variables in the sanitary/environmental category. As shown, the percent of the population with access to improved sanitation ranged from 9.5% in Niger to 100% in four countries: Uzbekistan, Republic of Korea, Israel, and Japan. With respect to the percent of the population with access to improved drinking water sources, the range recorded was from 40 to 100%. Papua New Guinea recorded the lowest, while as many as 22 countries recorded 100%.

Table 9 Detailed dataset used in the study

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Acheampong, M., Ejiofor, C. & Salinas-Miranda, A. An Analysis of Determinants of Under-5 Mortality across Countries: Defining Priorities to Achieve Targets in Sustainable Developmental Goals. Matern Child Health J 21, 1428–1447 (2017).

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