Spatial Patterns and Determinants of Under-Five Mortality in East Africa: ASpatial and Multilevel Levels Analysis

Abstract

Background: Sub-Saharan Africa is still the region having the highest burden of under-five mortality rate in the world. Of 5 million under-five deaths in 2021, more than 80 percent of under-five death reported from Sub-Saharan Africa and Southern Asia. Thus, the aim of this study was to assess the spatial patterns and identify determinant factors of under-five mortality among selected East Africa countries. Methods: A study was conducted using data from the Demographic and Health Survey (DHS) of 9 East African countries between 2016 and 2022. The study included a weighted sample of 115,335 live births within the 5 years prior to the survey for analysis. Due to the hierarchical nature of the DHS data, multilevel logistic regression models were used and model comparison was done using Likelihood ratio, AIC, and BIC. Bivariate analysis identified variables with p<0.2, which were considered for multivariable analysis. Among several appropriate models, the one that considered individual and community-level factors was found to be the most suitable for analyzing the data in this study.The sig nificant predictors of under-five mortality were determined in the multilevel logistic regression analysis, and this was reported using the adjusted odds ratio (AOR) along with a 95% Confidence Interval (CI) and with a p-value <0.05. XY coordinate data was also taken from the selected enumeration areas. A total of 6,736 clusters were included in this study to analyze the spatial patterns of under-five mortality. Results: This study revealed that the spatial distribution of under-five mortality was non-random in the region with Moran’s index 0.552 (P-value<0.001), with high-risk areas identified in Burundi, Madagascar, Uganda, and Ethiopia. Multiple births (AOR = 5.73, 95% CI: 5.01, 6.36), being male child (AOR = 1.29, 95% CI: 1.22, 1.37), born from mother who had no formal education(AOR = 1.57, 95% CI: 1.28,1.91), while children born to mothers with primary education (AOR = 1.17, 95% CI: 1.05-1.31) and children born into family sizes of more than four (AOR = 2.60, 95% CI: 2.41, 2.81) were significantly associated with an increased odds of under-5 mortality. Whereas being ≥ 5th birth order (AOR=0.72, 95% CI:0.64-0.82), health facility delivery (AOR = 0.83, 95% CI: 0.77, 0.89), born from mother who use contraceptive method(AOR=0.59,95% CI:0.5,0.71), children born from employed mother (AOR=0.90, 95% 0.84 , 0.97), and children delivered by Cesarean section (AOR =0.81, 95% CI: 0.72, 0.91) were significantly associated with a lower risk of under-5 mortality. Conclusion: Under-five mortality in East Africa is spatially clustered, with high-risk areas identified in Burundi, Madagascar, Uganda, and Ethiopia. Effective interventions are possible, as evidenced by the lower risk levels in Kenya and Rwanda. Findings suggest that family planning, increased access to education, and safe delivery practices are essential for reducing under-five mortality rates