Identifying factors determining the survival time of under- ve year children in rural parts of Ethiopia


 In Ethiopia, the remarkable progress in child survival was made. However, Ethiopia is ranked as fifth burden countries of under-five deaths, particularly in rural areas. Therefore, this study was aimed to identify determinants that causes under-five death in the rural parts of Ethiopia. Only 7301 women from rural residence who had under-five children were involved in this study. Descriptive, None-parametric and Cox proportional hazard regression analysis were used to examine the determinants associated with the under-five mortality. This study revealed that 6.5% of children were died before reaching their fifth birthday in the rural parts of Ethiopia. Sex, place of delivery, family size, Mother education, number of under-five children, contraceptive use and source of drinking water had significant effect on the survival time of under-five children. Conclusion: A significant risk factors associated with under-five mortality in rural areas were identified in this study. Children delivered at home, children from uneducated mothers, children from not using contraceptive method mothers, drink water from not piped source had higher risk of death. Giving awareness about benefits of delivering in health facility and uses of contraceptive method, improving mother education and infrastructure like sources of water, decreases mortality of under-five children.

Ethiopia ranked as fth of heavy under-ve deaths burdened countries of Sub-Saharan and Southern Asia regions [2]. But the country showed a major improvement with a gradual decline from 244.8 of 1970 to 50.7 deaths per thousand live births in 2019. This achievement was actually brought through improvements in overall socioeconomic conditions of the country and wider area coverage of health facilities with well interventions in prevention and/or treatments of the major causes of child mortality [14].
Socioeconomic and socio-demographic factors, and maternal, and child-related risk factors were reported on under-ve deaths of child with the worst situation in rural areas of Ethiopia. Several studies conducted across the country implied the signi cant effect of areas of residence on the under-ve death with higher prevalence in the rural areas than the urban ones [15], [16]. Another study which was done using EDHS 2011, also revealed 18.3% and 14% deaths of under-ve children in rural and urban residences, respectively [16]. Moreover, the World Health Organization (WHO) 2020 report from one-third of 47 low and middle-income countries presented that the death of under-ve was higher in rural residents than in urban by 20 deaths per 1000 live births [5].
An earlier study that used Ethiopia Demographic and Health Survey (EDHS) estimate of 2000, 2005 and 2011 revealed higher child mortalities in the rural parts of the country, where above 80% of the total population live. According to this report, having high number of children in the family rise the risk of maternal and children mortality [10], implying that children from mothers who didn't receive healthcare during pregnancy and post-delivery care had a greater risk of under-ve mortality than those of mothers who have received the treatment.
Moreover, another study conducted in Ethiopia, Sub-Saharan Africa and Nigeria also revealed that gender of family head, gender of children, household economic status and mother education status had signi cantly related with the mortality of under-ve children [17,18,8,15]. Children being born from educated women were related with reduced risk of under-ve mortality than children being born from uneducated women [15]. Decreasing these disproportions through the countries and saving more children lives remain a signi cant concern through interventions mechanisms that promote child survival [5].
Therefore, there are differences in risk factors determining the survival time of under-ve children in the rural parts of Ethiopia. Understanding the determinant factors of under-ve mortality and survival has signi cant importance (particularly important) to inform the public health o cials and policy designers design strategies to accelerate the reduction of under-ve mortality. And, this study was aimed to identify the factors that determine the survival time of under-ve children in the rural parts of Ethiopia.

Study Settings
According to 2018 estimate, the total population of Ethiopia was above 108 million, making it the 12th rapid population growth country in the world and the second most populous country in Africa, following Nigeria. More than 80% of the total population lives in rural areas, and the country's economy is predominantly agriculture based. Ethiopia's rapid population growth is putting the country in an increasing pressure on the land resources, an increase of land degradation and deforestation, and an increase in scarcity of basic necessities such as food.
The data for this study was extracted from 2016 Ethiopian Demographic and Health Survey, which was a population-based cross-sectional study collected between January 18, 2016 and June 27, 2016 through the country. This dataset is accessible online using the link received from DHS database https://www.dhsprogram.com/data/dataset_admin/login_main.cfm.
According to EDHS of 2016, the samples were selected in two phases. In the rst phase, 645 clusters (202 from urban and 443 from rural) were randomly selected proportional to the household extent from the sampling strata and secondly, 28 households per cluster were selected using systematic random sampling, and only rural clusters were incorporated in this study.
According to EDHS report data were collected using different questionnaires and the data of the child mortality and associated factors were obtained from a woman's questionnaire of women who met the eligibility criteria (women aged 15-49 years). From samples of 18,008 households proposed, 16, 650 households were interviewed for individual interview and 16, 583 quali ed women were identi ed from the interviewed household. About 15,683 women aged 15-49 interviews were completed [19]. Out of 10, 641 women were included due to having children preceding ve years survey to compute the under-ve mortality. Accordingly, 7,301 children born in rural areas between 2011 and 2015 in the 5 years prior to the assessment were considered in this investigation.

Study Variables
Time to death of under-ve children which was measured in months (0-59 month) between the prior ve years of the study was the response variable of the study. The under-ve child mortality was used as event and coded as 1 if the child was died and 0 if the child was survived during the survey. Predictor variables are place of delivery, sex of children, birth weight of children, gender and age of head of the family, family size, mother's age at rst birth, marriage to rst birth, current marital status, father's and mother's education, residence, religion, number of under-ve children, wealth index, ANC visit, contraceptive method use, toilet availability and source of drinking water were considered as predictor variables of this study.

Statistical Methods
All obtained data was cleaned, coded and examined by SPSS − 20 and R-version 3.6.2 statistical software packages. Descriptive analysis, none parametric estimation and Cox PH model were employed to examine the risk factors of under-ve mortality. The Cox proportional hazard regression model is one of the common model, which is a broadly applicable, and the most widely used method of survival analysis [20]. Predictor variables those found signi cant in the univariable analysis were involved in the multivariable Cox PH regression analysis, and estimated hazard ratios with p-value less than 5% were used to indicate statistical signi cance of the variable in multivariable analysis. Moreover, the log-rank test was also used to identify the association of survival times among the different groups of explanatory variable.

Results
Prevalence of under-ve children death associated with child related factors in rural Ethiopia From 7301 under-ve children eligible for this investigation, 6.5% were passed away before reaching their fth birthday. Out of a total participants, almost half (51.4%) of them were male and 59.7% were died preceding the ve-years of survey. More than three-fourths (77.2%) of the children were delivered at home while the rest (22.8%) were delivered at health centers and other places. About 41% of the under-ve children had been delivered with an average size, and the death proportions among those having larger than average size, average size and smaller than average size were 25.2%, 40.3% and 34.5%, respectively. However, the death proportion of children who were born at home was found exceedingly larger, 83% ( Table 1).

Prevalence of under-ve children death associated with parental related factors in rural Ethiopia
Approximately, 72% of mothers' of the study children were uneducated and 65.4% were in the age group of less than 20 years at their rst birth. The children's death proportion from uneducated and less than 20 years aged mothers were 76% and 63.4%, respectively. Above 83%, study children's mother were enrolled in ANC during their pregnancy less than 4 times, however, child mortality rate among these mothers were 83%. Moreover, 55.8% of the participants were from mothers that had not used contraceptive methods and the death proportion was reported to be 60.5%. Most of the heads of household were males (84%) and three-fourth of them were aged 30 years and above. About 53.1% and 17.9% children from uneducated father, and secondary and above educated father were died before their 5th year's birthday.

Prevalence of under-ve children death associated with household related factors in rural Ethiopia
Study participating children were drown from all regional states of Ethiopia, however, children from Oromia ( of the children were from families having four and above family size while the remaining (40.4%) were from families having less than four family-size. The death proportion among those having > 4 family were surprisingly large, 62.8% (Table 1).
None-parametric test for association of participants' information and survival time The Log rank test results showed that sex of children, family size, region of residence, religion, educational background of child's father and mother, number of under-ve child, wealth index and contraceptive method use were statistically signi cant (  (Table 3).
Moreover, children who were delivered in the health facility had a reduced under-ve mortality rate than children delivered at the home holding other variables constant (HR = 0.738, 95% CI = 0.572, 0.951). This implies that there is a signi cant association of child survival time and place of delivery. Children who were delivered at home had 26.2% more risk of mortality than children who were born in the health center. Additionally, family size is found to have a signi cant effect on under-ve children's mortality. An estimated hazard ratio of children whose family had three and above family size (HR = 1.256, 95% CI = 1.040, 1.517) implies that children from families having three and above family size is 1.256 times more likely to experience death than their counterpart (1-3 children). Children from a mother with secondary school and above educational background had a reduced risk of death compared to children from uneducated mothers (HR = 0.464, 95% CI = 0.301, 0.714). This result disclosed that children who were born from mothers with secondary school and above educational experience had 53.6% higher survival time compared to children from uneducated mothers ( Table 3).
The risk of death among under-ve children having three and above under-ve brothers and sisters in the household was 1.733 times higher than their counterpart (HR = 1.733, 95% CI = 1.120, 2.682), and these children had 73.3% higher risk of death compared to those having no any other under-ve children.
An estimated hazard ratio for children from mothers who practiced using contraceptive methods at a different time is (HR = 0.797, 95% CI = 0.662, 0.960), and this showed that mothers who experienced using contraceptive methods had a decreased in uence of under-ve mortality compared to women having not experienced any methods of contraception. The children from households not having piped water sources for drinking had an increased risk of death compared to children from families of having piped water (HR = 1.303, 95% CI = 1.044, 1.627), and it is indicated that children's from households having no piped drinking water sources were 1.303 times more likely to die than children from households of having piped water in rural parts of the country (Table 3).

Discussion
There is still a high proportion of under-ve child death globally with the highest burden in the rural areas of developing countries including Ethiopia. This study was intended to examine the risk factors associated with the mortality of under-5 children in rural parts of Ethiopia using the survival analysis method. Out of 7301 under-ve children involved in this study, 6.5% were died before reaching their fth birthday, and this study is in line with a study done in Northern Ghana that is (6.14%) [21]. However, it is found very low compared to previous study done in Ethiopia using EDHS data of 2011 (18.3%) [16]. And, it could imply the decreasing ratio of child death in the preceding ve years survey time of the country.
Out of the total died children, 59.7% were male and it is higher compared to reports of previously study in Ethiopia, 50.27% [16] but is in line with study done in the in rural areas of Northern Ghana 53.3% [21]. The higher nding of this study could be due to the variation of the study sites (rural versus urban).
As a whole, still this study implied higher mortality rate of children in rural parts of the country. Of all study children, 77.2% were given birth at home and among these the death proportion were very high (83%) indicating the impact of giving birth at home, and this is consistent with other studies in Ethiopia [15] and Southern Ghana [21].This can be considered as a good indicator for most of the mothers not attending the antenatal care visit properly and this could be due to the absence of health facilities that provides ANC in their localities.
To analyze the risk factors of under-ve death non-parametric and semi-parametric regressions were applied. Gender of child, place of delivery, family size, mother's educational status, number of under-ve child, use of contraceptive methods, and sources of drinking water were among identi ed factors of under-ve child death in the country. In this regard, female child had a reduced hazard of death than male, and it is in line with several studies conducted in Sub-Saharan region using a multi-country analysis of under-ve mortality [9], Ethiopia [22,23] and Ghana [24] and with estimates established by the UN Interagency Group for child mortality estimation [1].
Moreover, delivery place was meaningfully correlated with under-ve deaths and death rate of children delivered in the health facility had less risk of death than child delivered at home. This outcome is reliable with the previously reports from Ethiopia [15], Sub-Saharan region [9], Tigray regional state (qualitative study) of Ethiopia [25], and rural parts of Southern Tanzania [26]. This might be because of unavailability of enough health facilities in the nearby sites or their distant situation that might result in transportation problem.
The household size was found to be a signi cant determinant of under-ve death; accordingly, it is predictable that following the increase in number of household members there will be an increased underve death rate as well. The hazard of death for children from household size of 4 and above is 25.6% higher compared to children from a household of 1-3. This nding is supported by prior studies conducted Ethiopia [16] and [27]. Many researchers suggested the signi cant association of mothers' educational level with under-ve child mortality. This study also revealed that children from mothers having secondary school and above educational background had less risk of death than those from uneducated ones. This is in agreement with previously studies conducted in Gilgel-Gibe Field Research Center of Southwest Ethiopia [28] and the whole Ethiopia [16,23,29], Ghana [21,30,24], and countries of Sub-Saharan Africa [31].
A fewer number of under-ve child in the family had a proportionally reduced death rate. This nding implied that children from mothers of having three and above under-ve children in the household were 73.3% times more exposed to death in comparison with other under-ve children with lesser number of sisters and/or brothers. This is in agreement with two studies conducted in Sub-Saharan region [31], and Ghana [32]. Mothers who were reported to use different contraceptives had signi cantly reduced risk of their child's mortality when compared to mothers who did not use any types of contraceptive methods to plan their family size. This is also in line with studies conducted in Ethiopia [15] and Ghana [24]. Drinking water had found to be signi cantly associated with the death of under-ve children. As shown in this study, children from family's who did not use piped water for drinking had a higher risk of death than children from families that did use piped water. This is also reported in previous studies investigated in Ethiopia [16] and Ghana [24]. Nevertheless, it is very contradicting with other prior study conducted in Ethiopia [15]. This may be due to the variation of samples that this study targeted both urban and rural residing under-ve children.

Conclusion
This nding identi ed the factors that related with under-ve children mortality in the rural parts of Ethiopia using the Ethiopian Demographic Health Survey 2016. Applying Cox PH model variables such as female gender, child's birth in health facilities, having a mother with secondary school and above educational background, presence of 1-2 under-ve children in the household, and having mothers who practiced contraceptive method had reduced risk of under-ve death. While, children from 4 and above family size, 3 and above number of under-ve children, and birth from a family that did not use piped water sources for drinking had higher hazard of under-ve death in rural parts of the country. N/A (The secondary data was taken from the DHS data base) Consent for publication N/A y g into small-scale geographical inequalities from Census data,"," BMJ Open, pp. vol. 2, article no. e001421, 2012.