Abstract
Background: Global achievement of the sustainable development goal (SDG) 3.2.1, i.e., reducing the under-5 mortality rate (U5MR) to as low as 25/1000 live births by 2030, appears to be a race against the clock. The global annual rates of reduction (ARR) observed (2.1%) during the post-millennium development goal period (since 2015) were at least four times lower than the above-mentioned required ARR (9.2%). The estimates (ARR vs. required ARR) for Sub-Saharan Africa (2.9% vs. 13.1%) and Southern Asia (4.5% vs. 7.1%) also fell short of the requirement. Meanwhile, a recent 28% reduction in U5MR (between 2017-18 and 2022) appears to favour Bangladesh, a country in South Asia, as it puts the country on track to achieve SDG 3.2.1. However, higher reduction rates followed by remarkably sluggish reductions that the country has episodically experienced since 2000 warrant caution. Indeed, a high U5M reduction rate does not guarantee a consistent reduction in the future. Moreover, the proportions of deaths due to complex medical conditions like prematurity, birth asphyxia or pneumonia, which often demand extensive medical care, have remarkably increased in the recent two decades. It is likely that the effect of initiatives to reduce U5M became inadequate to counter these proportionally increasing complex causes of death, which led to episodic sluggish reduction rates or stagnancies. To ensure an effective reduction of under-5 mortality (U5M), it is important to understand why stagnancy occurred. Notably, U5M is a multifaceted problem as it is associated with various factors representing different domains of the Bangladeshi socio-administrative and economic context. Therefore, innovative approaches are required to generate knowledge and evidence on this complex issue. This PhD research pursued three novel research questions to extensively understand the stagnant U5MR reported in the Bangladesh Demographic and Health Survey 2017-18.1. How did the sociodemographic and health service-specific factors vary in explaining the overall/all-cause under-5 mortality rates between 2011 and 2017-18 in Bangladesh?
2. How did the sociodemographic and health service-specific factors vary in explaining the top four cause-specific under-5 mortality rates between 2011 and 2017-18 in Bangladesh?
3. Investigate the mediation pathways of sociodemographic and health service factors, for example, the factors that mediated the effect of parental education on under-5 mortality in Bangladesh between 2011 and 2017-18.
Methods: This research used the repeated cross-sectional survey data from the Bangladesh Demographic and Health Survey of 2011, 2014 and 2017-18 and used three analysis approaches to address the specific research questions. Studies 1, 2 and 3 applied multilevel multivariable logistic regression, multilevel multinomial logistic regression and mediation analysis using generalised structural equation modelling, respectively. A multilevel technique was adopted to adjust the estimates for the clustering of mortality risks at the household or at the community level. A multinomial approach was used to accommodate seven categories (alive and all six causes of death) in the outcome variable. A mediation approach was used to investigate the effect of parental education on U5M mediated (sequentially and parallel) through antenatal care uptake and the presence of a handwashing station in the household.
Results: The analysis of overall/all-cause U5M revealed that a rise in the U5M risk attributable to maternal age 18 years and younger, low level of maternal education, high maternal body mass index and absence of a handwashing station in the households contributed to a stagnant mortality rate. The analysis of the cause-specific deaths demonstrated that children born to mothers 18 years or younger, as well as twins or multiples, had a greater mortality risk from prematurity, birth asphyxia and possible serious infections. Moreover, greater pneumonia and prematurity-specific deaths were associated with non-utilisation of antenatal and postnatal care, respectively. The cause-specific analysis also revealed an increase (between 2011 and 2017-18 survey) in the predicted risk of prematurity-specific U5M among twins or multiples, children who did not receive postnatal care, children born to mothers 18 years or younger and mothers with no formal education, which also probably contributed to the stagnancy. Mediation analysis of parental education revealed a reducing and inconsistent effect of education on U5M mediated through antenatal care utilisation status and availability of hand washing stations in the household. Although the overall effect (both direct and indirect) of education reduced over time, the proportion of parental education’s mediated effect increased, from approximately 50% in 2011 to more than 100% in 2017-18.
Conclusion: The findings indicate that the effect of the initiatives to prevent U5M was inadequate, given the proportionate rise of complicated causes of U5M, which contributed to stagnancy. Integrating the findings of this thesis with existing literature, this study recommends adopting a more collaborative and comprehensive approach for strengthening the existing interventions: compulsory use of antenatal and postnatal care cards and strict monitoring of their use to improve the quality of care; early identification and careful monitoring of twin pregnancies through the continuum of care; updating school curriculum (using research-based evidence) by giving a greater emphasis on maternal and child health; more extensive approaches to prevent adolescent pregnancy; utilisation of the administrative committees like Upazila Health Management Committee to promote collaboration in the implementation of interventions to reduce U5M across different sectors.
| Date of Award | 2025 |
|---|---|
| Original language | English |
| Supervisor | Itismita MOHANTY (Supervisor) & Theo NIYONSENGA (Supervisor) |