Iddrisu Abdul-Karim, Boanyo Emmanuel
Department of Statistics, School of Social Sciences, Faculty of Social Sciences, University of Botswana, Gaborone, Botswana.
Department of Mathematics and Statistics, School of Science, University of Energy and Natural Resources, Sunyani, Ghana.
PLOS Glob Public Health. 2025 Sep 12;5(9):e0005179. doi: 10.1371/journal.pgph.0005179. eCollection 2025.
The risk of under-five mortality is a vital measure of healthcare system performance and directly reflects progress toward Sustainable Development Goal (SDG) 3.2, which targets the elimination of preventable deaths among newborns and children under-five, aiming to reduce mortality rates to at least 25 per 1,000 live births by 2030. While Ghana has made notable progress in lowering child mortality in recent decades, the current rates remain above this benchmark. Identifying the predictors of under-five mortality is therefore critical for shaping evidence-based policies and targeted interventions that can accelerate progress toward SDG 3 and improve child health outcomes. To explore these predictors, we employed advanced survival modeling techniques. The conventional Cox-proportional hazards (Cox-PH) model assumes constant covariate effects over time, but violations of this assumption can lead to biased results. To address this, we used the extended Cox-PH model, which accommodates time-varying effects. Data were drawn from the 2022 Ghana Demographic and Health Survey (GDHS), based on a stratified two-stage cluster sampling design. Since under-five deaths are relatively rare (<10%), traditional models may yield unstable hazard ratios. We therefore applied Bayesian survival analysis to obtain more stable estimates and incorporated multilevel survival modeling to account for unobserved heterogeneity within the DHS sampling structure. Results showed that male children (HR = 1.20, 95% CI: 1.11-1.30) and twins (HR = 2.90, 95% CI: 2.51-3.34) faced higher mortality risk. Caesarean delivery (HR = 1.60, 95% CI: 1.08-2.37) and larger birth size also increased hazards. In contrast, term birth (HR = 0.16, 95% CI: 0.14-0.19), maternal education, and higher household wealth were protective. Children requiring special attention after delivery had improved survival (HR = 0.57, 95% CI: 0.38-0.89). Strengthening maternal and newborn care, coupled with addressing socioeconomic inequalities, is essential to reducing child mortality and achieving Ghana's SDG 3.2 targets.
五岁以下儿童死亡率是衡量医疗系统绩效的一项重要指标，直接反映了在实现可持续发展目标3.2方面所取得的进展。该目标旨在消除新生儿和五岁以下儿童的可预防死亡，目标是到2030年将死亡率降至每1000例活产至少25例。尽管加纳近几十年来在降低儿童死亡率方面取得了显著进展，但目前的死亡率仍高于这一基准。因此，确定五岁以下儿童死亡率的预测因素对于制定基于证据的政策和有针对性的干预措施至关重要，这些政策和措施可以加速实现可持续发展目标3并改善儿童健康状况。为了探索这些预测因素，我们采用了先进的生存建模技术。传统的Cox比例风险（Cox-PH）模型假定协变量效应随时间恒定，但违反这一假设可能导致有偏差的结果。为了解决这个问题，我们使用了扩展的Cox-PH模型，该模型考虑了随时间变化的效应。数据来自2022年加纳人口与健康调查（GDHS），基于分层两阶段整群抽样设计。由于五岁以下儿童死亡相对较少（<10%），传统模型可能会产生不稳定的风险比。因此，我们应用贝叶斯生存分析来获得更稳定的估计值，并纳入多层次生存建模以考虑DHS抽样结构中未观察到的异质性。结果表明，男童（HR = 1.20，95% CI：1.11 - 1.30）和双胞胎（HR = 2.90，95% CI：2.51 - 3.34）面临更高的死亡风险。剖宫产（HR = 1.60，95% CI：1.08 - 2.37）和出生体重较大也会增加风险。相比之下，足月出生（HR = 0.16，95% CI：0.14 - 0.19）、母亲受教育程度和家庭财富较高则具有保护作用。产后需要特别护理的儿童生存情况有所改善（HR = 0.57，95% CI：0.38 - 0.89）。加强孕产妇和新生儿护理，同时解决社会经济不平等问题，对于降低儿童死亡率和实现加纳的可持续发展目标3.2至关重要。
