Abstract
BackgroundThe under-5 mortality rate (U5MR) is an important metric of child health and survival. Country-level estimates of U5MR are readily available, but efforts to estimate U5MR subnationally have been limited, in part, due to spatial misalignment of available data sources (e.g., use of different administrative levels, or as a result of historical boundary changes).MethodsWe analyzed all available complete and summary birth history data in surveys and censuses in six countries (Bangladesh, Cameroon, Chad, Mozambique, Uganda, and Zambia) at the finest geographic level available in each data source. We then developed small area estimation models capable of incorporating spatially misaligned data. These small area estimation models were applied to the birth history data in order to estimate trends in U5MR from 1980 to 2015 at the second administrative level in Cameroon, Chad, Mozambique, Uganda, and Zambia and at the third administrative level in Bangladesh.ResultsWe found substantial variation in U5MR in all six countries: there was more than a two-fold difference in U5MR between the area with the highest rate and the area with the lowest rate in every country. All areas in all countries experienced declines in U5MR between 1980 and 2015, but the degree varied both within and between countries. In Cameroon, Chad, Mozambique, and Zambia we found areas with U5MRs in 2015 that were higher than in other parts of the same country in 1980. Comparing subnational U5MR to country-level targets for the Millennium Development Goals (MDG), we find that 12.8% of areas in Bangladesh did not meet the country-level target, although the country as whole did. A minority of areas in Chad, Mozambique, Uganda, and Zambia met the country-level MDG targets while these countries as a whole did not.ConclusionsSubnational estimates of U5MR reveal significant within-country variation. These estimates could be used for identifying high-need areas and positive deviants, tracking trends in geographic inequalities, and evaluating progress towards international development targets such as the Sustainable Development Goals.
Highlights
The under-5 mortality rate (U5MR) is an important metric of child health and survival
Subnational estimates could be used in monitoring progress towards development goals such as the Sustainable Development Goal (SDG) and Millennium Development Goals (MDG) to ensure that certain geographic regions are not systematically left behind
Between 1980 and 2015, U5MR improved in all sub-districts, with relative declines ranging from 70% (43, 87) in Jhikargachha sub-district to 87% (75, 94) in Barisal sub-district
Summary
The under-5 mortality rate (U5MR) is an important metric of child health and survival. Country-level estimates of U5MR are available globally from a number of sources [3, 4]; detailed subnational estimates (e.g., at the second administrative level) are not widely available This is unfortunate, as subnational estimates are essential for measuring inequalities and are important for public health planning and evaluation purposes. U5MR is usually estimated on the basis of birth history data collected in surveys and censuses, wherein women are interviewed about their children’s survival. Methods for analyzing these data have been available for decades [5, 6] and have been widely applied at the country level. The number of child deaths in any given survey within a limited geographic area is generally quite small and estimates based on a small number of events are subject to random fluctuations
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