Determinant factors of under-five mortality in Southern Nations, Nationalities and People’s region (SNNPR), Ethiopia

Child mortality is a key indicator of the performance of the health system of a nation [1] Remarkable progress in the reduction of mortality among children including children under the age of five has been made globally. In 1990, an estimated 12.6 million deaths occurred among under the age five children and it declined to 5.3 million in 2018. Of the deaths occurred among under the age of five in 2018, 2.5 million (47%) deaths occurred in the first month of life, 1.5 million (29%) deaths occurred at age 1–11 months, and 1.3 million (25%) deaths occurred at age 1–4 years. Sub-Saharan Africa accounts roughly half of all the deaths occurred among under-five children worldwide in 2018. The global under-five mortality rate has dropped by 59%, from 93 deaths per 1000 live births in 1990 to 39 deaths per 1000 live births in 2018. This is equivalent to 1 in 11 children dying before reaching age five in 1990, compared to 1 in 26 in 2018 [2].

There are widespread regional and income disparities in children’s chances of survival with the WHO African region carrying the highest burden of under-five mortality in the world. Sub-Saharan Africa continues to be the region with the highest risk of dying before the age five in the world with 78 deaths per 1000 live births in 2018. This means that 1 child in 13 dying his or her before their fifth birthday, which is 16 times higher than the average ratio of 1 child in 199 in high-income countries and 20 times higher than in the region of Australia and New Zealand [2].

In Ethiopia, according to the recent Ethiopian Demographic and Health Survey (2016 EDHS) report, the under-five mortality rate was 67 deaths per 1000 live births, which means 1 in 15 children in Ethiopia dies before reaching age five. The under-five mortality declined from 166 deaths per 1000 live births in 2000 to 67 deaths per 1000 live births in 2016 in the country, which represents a 60% decrease in under-five mortality over a period of 16 years [3].

Though Ethiopia made an improvement in reduction of under-five mortality in the past two decades, still it is high and therefore more efforts need to be made and appropriate interventions also need to be implemented to meet the Sustainable Development Goals (SDGs) that targeted to reduce under-five mortality rate to at least as low as 25 deaths per 1000 live births by 2030.

In Ethiopia, the under-five mortality rate varies among the geographical regions [4‐7]. Southern Nations Nationalities and People’s Region is one of the geographical regions of Ethiopia with high under-five mortality rates [3, 4]. The 2016 EDHS reported that in SNNPR under-five mortality rate was 88 deaths per 1000 live births [3].

Previously conducted studies showed that under-five mortality is determined by various factors including sex of child [8‐11], birth order [8, 11‐14] size of child at birth [5, 11, 13, 15] breastfeeding status [11, 12, 14‐17] preceding birth interval [11‐13, 16, 17] type of birth [11, 12, 15‐18], place of delivery [8, 11]. Studies also showed that under-five mortality is determined by mother’s age [11] mother age at first birth [4, 5, 10‐12, 15] mother’s education [4, 5, 8, 10, 11, 15], sex of the household head [9], household socioeconomic status [4, 16, 17, 19] contraceptive methods use [13, 15], family size [10, 12, 13, 16, 17], types of place of living [11, 13], source of drinking water and toilet facility [9, 12, 16, 17], religion, marital status and employment status of mother [4, 11].

To my knowledge, there is no study that has been done at regional level in SNNPR on determinant factors of Under-five mortality. Identifying the determinant factors that are associated with under-five mortality is important to inform policy makers to provide relevant alternative interventions or strengthen the existing interventions so as to reduce under-five mortality to the level it is expected. Thus, this study aimed to identify determinant factors associated with under-five mortality in SNNPR, Ethiopia.

Of the total of 1277 under-five children included in this study, 71(5.6%) of them were reported dead before the age of 5 years. Majority (92.6%) of the children were living in rural areas while the remaining 7.4% of them were living in urban areas. 51.4% of the children were males and the remaining 48.6% of them were females. Majority (98%) of the children’s birth type was single and only 2% of the children’s birth type was multiple. About two-third (67.5%) of the children were breastfed while the remaining 32.5% were not. More than two-third (70.9%) of the children were born at home and only 29.1% of them were born at health institutions. The majority (30.5%) of the children had birth order of second or third, about 24% of them had birth order of fourth or fifth, 18% of them had birth order of first and the remaining 27.3% of them had birth order of sixth or above. Majority (44.4%) of the children had average size, about 34.4% of them had size of above average while the remaining 21.2% of them had size of below average at birth. More than two-third (72.8%) of the children were from families with family size of five or more while the remaining 27.2% of them were from families with family size of less than five (Table 5).

The result of the multivariate logistic regression analysis revealed that male children were at higher risk of under-five mortality compared to female children. This result is consistent with the result of previous studies [9, 11, 20‐22]. The possible explanation for this might be that male children are biologically weaker than their female counterparts due to a fundamental genetic advantage.

Children of higher birth order had higher risk of under-five mortality compared to those children of lower birth order. This is consistent with the previous study [13, 16]. The reason for this might be that as birth order increases care given to child by mother decreases because of having more children.

It was found that children from larger family size were more likely to die before the age of 5 years compared to those children from smaller family size. This is consistent with findings of the previously done studies [13, 17]. This might be due to that as family size increases, the share of foods and other limited sources required for the child survival decreases.

Children born at home were more likely to die before the age of 5 years compared to those born at health institutions. This result agrees with the finding of the previous study [8, 16]. This might be due to the fact that children born at home are more susceptible to infections.

It was also found that children who were breastfed were associated with lower odds of under-five mortality compared to those who were not breastfed. This result is consistent with the results of previous studies [10, 14, 17]. The possible explanation for this might be that breast milk helps build and support baby’s immune system that defends body against invaders, such as viruses and bacteria.

It was also found that children of multiple births were at higher risk of under-five mortality compared to singletons. This is consistent with findings of the previously studies [5, 17, 18, 20]. The possible explanation for this might be that foods and other limited resources and care given to child by mother are shared.

Children with smaller size at birth were found to have higher odds of under-five mortality than those with larger size at birth. This result agrees with the result of previous study [16].

The study aimed at identifying the determinants of under-five mortality in Southern Nations Nationalities and People Region, Ethiopia. A total of 1277 under- five children were included in the study. It was found that sex of a child, birth order, size of a child at birth, place of delivery, birth type, breastfeeding status, and family size were significant determinants of under-five mortality in SNNPR, Ethiopia.

One of the limitations of this study was that factors such as preceding birth interval, number of antenatal care visits during pregnancy, which are supposed to be associated with under-five mortality were not included in the study because of high missing values in the data. The other limitation was that mothers might forget events that occurred in the past 5 years preceding the survey which could have introduced recall bias.