Survival analysis of under-five mortality and associated risk factors using survival analysis approaches.

Abstract

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.