Khan Jahidur Rahman, Awan Nabil
Institute of Statistical Research and Training (ISRT), University of Dhaka, Dhaka, 1000 Bangladesh.
Arch Public Health. 2017 Sep 7;75:58. doi: 10.1186/s13690-017-0224-6. eCollection 2017.
Bangladesh has experienced a significant reduction of child mortality over the past decades which helped achieve the Millennium Development Goal 4 (MDG 4) target. But the mortality among under-5 aged children is still relatively high and it needs a substantial effort to achieve the Sustainable Development Goal (SDG) target and decelerate the current rate of under-5 mortality. At this stage, it is hence important to explore the trend and determinants of under-5 mortality in order to reduce the vulnerability of child's survival. The aim of this study is to explore the trends and identify the factors associated with mortality in children aged less than 5 years in Bangladesh.
Data from three repeatedly cross-sectional Bangladesh Demographic and Health Surveys (BDHSs) for the year 2007, 2011 and 2014 were used. A stratified two-stage sampling method was used to collect information on child and maternal health in these surveys. Cox's proportional hazards models with community and mother level random effects (or frailty models) were fitted to identify the associated factors with under-five mortality.
Our study reveals that urban-rural disparity in child mortality has decreased over the time. The frailty models revealed that the combined effect of birth order and preceding birth interval length, sex of the child, maternal age at birth, mother's working status, parental education were the important determinants associated with risk of child mortality. The risk of mortality also varied across divisions with Sylhet division being the most vulnerable one. Moreover, significant and sizable frailty effects were found which indicates that the estimations of the unmeasured and unobserved mother and community level factors on the risk of death were substantively important.
Our study suggests that community-based educational programs and public health interventions focused on birth spacing may turn out to be the most effective. Moreover, unobserved community and familial effects need to be considered along with significant programmable determinants while planning for the child survival program.
在过去几十年里，孟加拉国儿童死亡率显著下降，这有助于实现千年发展目标4（MDG 4）的指标。但5岁以下儿童的死亡率仍然相对较高，要实现可持续发展目标（SDG）指标并减缓当前5岁以下儿童死亡率的下降速度，仍需付出巨大努力。在此阶段，探索5岁以下儿童死亡率的趋势和决定因素对于降低儿童生存的脆弱性至关重要。本研究的目的是探讨孟加拉国5岁以下儿童死亡率的趋势，并确定与之相关的因素。
使用了2007年、2011年和2014年三次孟加拉国人口与健康调查（BDHSs）的重复横断面数据。在这些调查中，采用分层两阶段抽样方法收集儿童和孕产妇健康信息。拟合了具有社区和母亲层面随机效应的Cox比例风险模型（或脆弱模型），以确定与5岁以下儿童死亡率相关的因素。
我们的研究表明，儿童死亡率的城乡差距随着时间的推移有所缩小。脆弱模型显示，出生顺序和上次生育间隔长度、孩子性别、母亲生育年龄、母亲工作状况、父母教育程度的综合影响是与儿童死亡风险相关的重要决定因素。死亡率风险在各行政区也有所不同，锡尔赫特行政区最为脆弱。此外，还发现了显著且可观的脆弱效应，这表明未测量和未观察到的母亲和社区层面因素对死亡风险的估计具有实质性重要意义。
我们的研究表明，以社区为基础的教育项目和侧重于生育间隔的公共卫生干预措施可能是最有效的。此外，在规划儿童生存项目时，除了重要的可规划决定因素外，还需要考虑未观察到的社区和家庭影响。
