Assessment of trends and determinants of under-five mortality among children born to older women: Evidence from Ethiopian demographic and health surveys

INTRODUCTION: Under-five mortality has long been used as an indicator of the level of socio-economic development of a country. Global attention has been given to the issue through the Sustainable Development Goals, yet the burden continues to be disproportionately concentrated in Sub-Saharan Africa and South Asia. Ethiopia is one of six nations that together account for half of global under-five mortality, with particular burden observed among children born to older mothers. Hence, this study aimed to determine the magnitude of under-five mortality among children born from elder mothers, assess its trend over time, and identify associated factors. METHODS: Data were drawn from the nationally representative Ethiopia Demographic and Health Surveys (EDHS) conducted in 2000, 2005, 2011, and 2016. The analytic sample comprised 6,199 children born to women aged 35-49 years in the five years preceding each survey. Information on mother and child characteristics, socio-economic factors, and environmental variables was collected through face-to-face household interviews. Descriptive statistics characterized the study participants. Multilevel binary logistic regression was used to estimate adjusted odds ratios and 95% confidence intervals for factors associated with under-five mortality. RESULT: Under five mortality declined from 128 per 1000 live births during the year 2000-56 per 1000 live births in 2016. This study identified several factors contributing for under-five mortality among children of women aged 35-49 years. Protective factors included female child sex (AOR = 0.65, 95% CI: 0.53-0.79), maternal age at first birth of 31-40 years (AOR = 0.34, 95% CI: 0.11-0.98), family size of 6-10 members (AOR = 0.18, 95% CI: 0.14-0.24), birth interval greater than 3 years (AOR = 0.35, 95% CI: 0.26-0.47), and 1-3 antenatal care visits (AOR = 0.65, 95% CI: 0.50-0.84). In contrast, the following factors increased the odds: twin birth (AOR = 6.15, 95% CI: 3.94-9.60), four births in the last five years (AOR = 2.64, 95% CI: 1.15-6.06), nine or more children ever born (AOR = 3.79, 95% CI: 2.10-6.84), and maternal age at birth of the index child of 45-49 years (AOR = 2.13, 95% CI: 1.55-2.93). CONCLUSION: The decline in under-five mortality over the last 16 years in Ethiopia represents promising progress toward the targets set out in the Sustainable Development Goals and national health policy. However, targeted programs and interventions focusing on provision of the recommended antenatal care, adequate birth spacing, limiting the number of births within short intervals, discouraging pregnancies after age 40, and supporting smaller family sizes are essential to further reduce under-five mortality. The study findings highlight the importance of risk-pregnancy screening, well-spaced pregnancies, family health promotion, and strengthened childhood illness prevention and treatment services.