A Multilevel Decomposition of Time Variation in the Risks of Infant Mortality in Rural Uganda: UDHS 1995–2016
The study assessed the contribution of maternal, child, paternal, household, proximate, and community-level factors to infant mortality risk time variation in rural Uganda between 1995 and 2016. Five rounds of Uganda Demographic and Health Survey data sets were used, and a multilevel mixed-effect logistic regression model was applied to decompose the contribution of different factors to time variation in the risks of infant mortality. All live births that were made five years before the surveys of 1995, 2001, 2006, 2011, and 2016 were considered, with infants who did not survive beyond one year treated as the outcome variable analysis, excluding those who were born less than 12 months before the survey. The fixed part of the model helped us detect the significant variables in determining infant mortality, and yet the random part of the model helped us quantify the amount of time variation in the risks of infant mortality explained by the selected variables. The child-level determinants of infant mortality were sex, birth order, and weight. Among the maternal factors, the study revealed that marital status, access to ANC, use of contraceptives, maternal education level, and preceding birth interval were consistent deterrents of infant mortality, while household size, sanitation, and wealth index remained critical. While controlling for other factors in the rural areas, time variation in the risks of infant mortality was dependent on community factors (such as region, community hygiene, and prenatal care utilization rate), proximate factors (such as access to prenatal care, contraceptives use, place of delivery, and the number of ANC visits), maternal factors (such as marital status, educational level, age, parity, preceding birth interval, desire for pregnancy, and breastfeeding), and endowment. It was observed that the changes in the risks of infant mortality over the period were explained by community (30.7%), proximate (22.7%), maternal (41.0%), and endowment (37.9%). Child-level factors explained 28.2%, and paternal-level education level explained only 30.1%. Remarkably, household-level factors captured 32.3% of the changes in infant mortality. A higher proportion of the explained variation in the risk of infant mortality across communities (PCV) was captured by child, paternal, maternal endowment, and household factors. Interventions to accelerate the reduction in infant mortality should target birth spacing to at least two years, girl child education to at least o level, joint household decision-making in having children, avoiding teenage pregnancies, postnatal care utilization, enforcing at least four ANC visits during pregnancy, improving household sanitation, and increasing access to safe water at household-levels
Acheampong, G. K., & Avorgbedor, Y. E. J. J. o. P. H. R. (2017). Determinants of under Five Mortality in Ghana; A Logistic Regression Analysis Using Evidence from the Demographic and Health Survey (1988-2014). 5(3), 70-78.
Adedini, S. A., Odimegwu, C., Bamiwuye, O., Fadeyibi, O., & Wet, N. D. (2014). Barriers to accessing health care in Nigeria: implications for child survival. Global health action, 7(1), 23499.
Adedini, S. A., Odimegwu, C., Imasiku, E. N., Ononokpono, D. N., & Ibisomi, L. (2015). Regional variations in infant and child mortality in Nigeria: a multilevel analysis. Journal of biosocial science, 47(2), 165-187.
Adedini, S. A., Odimegwu, C., Bamiwuye, O., Fadeyibi, O., & Wet, N. D. (2014). Barriers to accessing health care in Nigeria: implications for child survival. Global health action (7(1)).
Ahmed, Z., Kamal, A., & Kamal, A. (2016). Statistical analysis of factors affecting child mortality in Pakistan. J Coll Physicians Surg Pak, 26(6), 543-544.
Antai, D. J. B. p. h. (2011). Controlling behavior, power relations within intimate relationships and intimate partner physical and sexual violence against women in Nigeria. 11(1), 511.
Ayiko, R., Antai, D., & Kulane, A. (2009). Trends and determinants of under-five mortality in Uganda. East African Journal of public health, 6(2), 136-140.
Boco, A. G. J. D., & Paper, H. S. W. (2010). Individual and community level effects on child mortality: an analysis of 28 demographic and health surveys in Sub-Saharan Africa.
Corman, H., & Grossman, M. (1985). Determinants of neonatal mortality rates in the US: A reduced form model. Journal of health economics, 4(3), 213-236.
Davis, K. D., Lawson, K. M., Almeida, D. M., Kelly, E. L., King, R. B., Hammer, L., . . . McHale, S. M. (2015). Parents’ daily time with their children: A workplace intervention. Paediatrics, 135(5), 875-882.
Desai, S., & Alva, S. (1998). Maternal education and child health: Is there a strong causal relationship? Demography, 35(1), 71-81.
Desai, S., & Alva, S. J. D. (1998). Maternal education and child health: Is there a strong causal relationship?, 35(1), 71-81.
Diez Roux, A. V. (2004). Estimating neighbourhood health effects: the challenges of causal inference in a complex world.
Ezeh, O. K., Agho, K. E., Dibley, M. J., Hall, J., & Page, A. N. (2014a). Determinants of neonatal mortality in Nigeria: evidence from the 2008 demographic and health survey. BMC Public Health, 14(1), 521.
Ezeh, O. K., Agho, K. E., Dibley, M. J., Hall, J. J., & Page, A. N. (2014b). The effect of solid fuel use on childhood mortality in Nigeria: evidence from the 2013 cross-sectional household survey. Environmental Health, 13(1), 1-10.
Ezeh, O. K., Uche-Nwachi, E. O., Abada, U. D., & Agho, K. E. (2019). Community-and proximate-level factors associated with perinatal mortality in Nigeria: evidence from a nationwide household survey. BMC Public Health, 19(1), 1-9.
Forouzanfar, M. H., Afshin, A., Alexander, L. T., Anderson, H. R., Bhutta, Z. A., Biryukov, S., . . . Charlson, F. J. (2016). Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. The Lancet, 388(10053), 1659-1724.
Frankenberg, E. (1995). The effects of access to health care on infant mortality in Indonesia. Health transition review, 143-163.
Frankenberg, E. J. H. t. r. (1995). The effects of access to health care on infant mortality in Indonesia. 143-163.
GA, U. (2015). Transforming our world: the 2030 Agenda for Sustainable Development. Division for Sustainable Development Goals: New York, NY, USA.
Garosi, E., Mohammadi, F., & Ranjkesh, F. (2016). The relationship between neonatal jaundice and maternal and neonatal factors. Iranian Journal of Neonatology IJN, 7(1), 37-40.
Gelman, A. J. B. a. (2006). Prior distributions for variance parameters in hierarchical models (comment on article by Browne and Draper). 1(3), 515-534.
Golding, N., Burstein, R., Longbottom, J., Browne, A. J., Fullman, N., Osgood-Zimmerman, A., . . . Casey, D. C. (2017). Mapping under-5 and neonatal mortality in Africa, 2000–15: a baseline analysis for the Sustainable Development Goals. The Lancet, 390(10108), 2171-2182.
Griffiths, P., Madise, N., Whitworth, A., & Matthews, Z. (2004). A tale of two continents: a multilevel comparison of the determinants of child nutritional status from selected African and Indian regions. Health & place, 10(2), 183-199.
Haddad, L., Achadi, E., Bendech, M. A., Ahuja, A., Bhatia, K., Bhutta, Z., . . . De Onis, M. (2015). The Global Nutrition Report 2014: actions and accountability to accelerate the world’s progress on nutrition. The Journal of nutrition, 145(4), 663-671.
Hill, K. (2003). Frameworks for studying the determinants of child survival. Bulletin of the World Health Organization, 81, 138-139.
Hox, J. J. (1995). Applied multilevel analysis: TT-publikaties.
Hug, L., Alexander, M., You, D., Alkema, L., & for Child, U. I.-a. G. (2019). National, regional, and global levels and trends in neonatal mortality between 1990 and 2017, with scenario-based projections to 2030: a systematic analysis. The Lancet Global Health, 7(6), e710-e720.
ICF, U. B. o. S. U. a. (2017). 2016 Uganda Demographic and Health Survey. Retrieved from Kampala, Uganda, and Rockville, Maryland, USA:
Jain, N., Singh, A., & Pathak, P. (2013). Infant and child mortality in India: trends in inequalities across economic groups. Journal of Population Research, 30(4), 347-365.
Kamal, S. M. (2012). Maternal education as a determinant of neonatal mortality in Bangladesh. Journal of Health Management, 14(3), 269-281.
Kananura, R. M., Tetui, M., Mutebi, A., Bua, J. N., Waiswa, P., Kiwanuka, S. N., . . . Makumbi, F. (2016a). The neonatal mortality and its determinants in rural communities of Eastern Uganda. Reproductive health, 13, 1-9.
Kananura, R. M., Tetui, M., Mutebi, A., Bua, J. N., Waiswa, P., Kiwanuka, S. N., . . . Makumbi, F. (2016b). The neonatal mortality and its determinants in rural communities of Eastern Uganda. Reproductive health, 13(1), 13.
Kassebaum, N. J., Barber, R. M., Bhutta, Z. A., Dandona, L., Gething, P. W., Hay, S. I., . . . Lim, S. S. (2016). Global, regional, and national levels of maternal mortality, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. The lancet, 388(10053), 1775-1812.
Kayode, G. A., Ansah, E., Agyepong, I. A., Amoakoh-Coleman, M., Grobbee, D. E., & Klipstein-Grobusch, K. (2014a). Individual and community determinants of neonatal mortality in Ghana: a multilevel analysis. BMC pregnancy and childbirth, 14, 1-12.
Kayode, G. A., Ansah, E., Agyepong, I. A., Amoakoh-Coleman, M., Grobbee, D. E., & Klipstein-Grobusch, K. (2014b). Individual and community determinants of neonatal mortality in Ghana: a multilevel analysis. BMC pregnancy and childbirth, 14(1), 165.
Kolenikov, S., & Angeles, G. (2005). The Use of Discrete Data in Principal Component Analysis With Applications to Socio-Economic Indices. CPC/MEASURE Working paper No. WP-04-85. In: Retrieved.
Kousar, S., Zafar, M., Sabir, S. A., & Sajjad, A. (2019). A Step toward Realization of Vision 2030; Reduction in Child Mortality: New Evidence from South Asian Countries. Journal of Independent Studies & Research: Management & Social Sciences & Economics, 17(1).
Lee, A. C., Kozuki, N., Cousens, S., Stevens, G. A., Blencowe, H., Silveira, M. F., . . . Adair, L. S. (2017). Estimates of burden and consequences of infants born small for gestational age in low and middle income countries with INTERGROWTH-21st standard: analysis of CHERG datasets. bmj, 358.
Mosley, W. H., & Chen, L. C. (1984). An analytical framework for the study of child survival in developing countries. Population and development review, 10, 25-45.
Mutunga, C. (2007). Environmental Determinants of Child Mortality in Kenya, UNU-WIDER Research paper No. 2007/83. Helsinki: United Nations University World Institute for Development Economics Research. Determinants of Child Mortality in Oyo State, Nigeria.
Mutunga, C. J. (2011). Environmental determinants of child mortality in Kenya. In Health inequality and development (pp. 89-110): Springer.
Nagot, N., Kankasa, C., Tumwine, J. K., Meda, N., Hofmeyr, G. J., Vallo, R., . . . Sunday, A. (2016). Extended pre-exposure prophylaxis with lopinavir–ritonavir versus lamivudine to prevent HIV-1 transmission through breastfeeding up to 50 weeks in infants in Africa (ANRS 12174): a randomised controlled trial. The Lancet, 387(10018), 566-573.
Nalwadda, C. K. (2014). Seeking referral care for newborns in Eastern Uganda: Community health workers’ role, caretakers’ compliance and provision of care.
Nasejje, J. B., & Mwambi, H. (2017). Application of random survival forests in understanding the determinants of under-five child mortality in Uganda in the presence of covariates that satisfy the proportional and non-proportional hazards assumption. BMC research notes, 10(1), 459.
Nasejje, J. B., Mwambi, H. G., & Achia, T. N. (2015). Understanding the determinants of under-five child mortality in Uganda including the estimation of unobserved household and community effects using both frequentist and Bayesian survival analysis approaches. BMC Public Health, 15(1), 1003.
O’hare, B. A., & Southall, D. P. J. J. o. t. R. S. o. M. (2007). First do no harm: the impact of recent armed conflict on maternal and child health in Sub-Saharan Africa. 100(12), 564-570.
Organization, W. H. (2019). Trends in maternal mortality 2000 to 2017: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division.
Owor, M. O., Matovu, J. K., Murokora, D., Wanyenze, R. K., & Waiswa, P. (2016). Factors associated with adoption of beneficial newborn care practices in rural eastern Uganda: a cross-sectional study. BMC pregnancy and childbirth, 16(1), 83.
Rwashana, A. S., Nakubulwa, S., Nakakeeto-Kijjambu, M., & Adam, T. (2014a). Advancing the application of systems thinking in health: understanding the dynamics of neonatal mortality in Uganda. Health research policy and systems, 12(1), 36.
Rwashana, A. S., Nakubulwa, S., Nakakeeto-Kijjambu, M., & Adam, T. (2014b). Advancing the application of systems thinking in health: understanding the dynamics of neonatal mortality in Uganda. Health research policy and systems, 12, 1-14.
Rwashana, A. S., Nakubulwa, S., Nakakeeto-Kijjambu, M., & Adam, T. (2014). Advancing the application of systems thinking in health: understanding the dynamics of neonatal mortality in Uganda. Health research policy and systems (12(1)), 36.
Singh, M. P., & Singh, R. (2017). Study on child mortality determinants in EAG states and Assam. Journal of Statistics Applications & Probability, 6(3), 533-547.
Ssewanyana, S., & Younger, S. D. (2008). Infant mortality in Uganda: Determinants, trends and the millennium development goals. Journal of African Economies, 17(1), 34-61.
Stenström Johansson, J. (2016). Determinants of under-5 mortality in Uganda: an econometric analysis.
Titaley, C. R., Dibley, M. J., Agho, K., Roberts, C. L., & Hall, J. (2008). Determinants of neonatal mortality in Indonesia. BMC Public Health, 8(1), 232.
Tom, A., Bosker, T. A. S. R. J., & Bosker, R. J. (1999). Multilevel analysis: an introduction to basic and advanced multilevel modeling: sage.
Unicef, W. J. G. W., & UNICEF. (2013). Ending preventable child deaths from pneumonia and diarrhoea by 2025: The integrated Global Action Plan for Pneumonia and Diarrhoea (GAPPD).
Wang, H., Bhutta, Z. A., Coates, M. M., Coggeshall, M., Dandona, L., Diallo, K., . . . Gething, P. W. (2016). Global, regional, national, and selected subnational levels of stillbirths, neonatal, infant, and under-5 mortality, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015. The Lancet, 388(10053), 1725-1774.
Whitworth, A., & Stephenson, R. (2002). Birth spacing, sibling rivalry and child mortality in India. Social science & medicine, 55(12), 2107-2119.
Zanini, M. T. F., & Migueles, C. P. (2013). Trust as an element of informal coordination and its relationship with organizational performance. EconomiA, 14(2), 77-87.
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