Rates and causes of neonatal and under-five mortality: insights from a national household survey in Pakistan

Background: Neonatal and under-five mortality rates are critical indicators of a country's health status and progress toward Sustainable Development Goals. Despite a decline in mortality rates globally, preventable child deaths continue to occur, particularly in Pakistan, which has one of the highest child mortality rates in the world. In this analysis, we present the latest cause-specific neonatal and under-five mortality estimates determined through verbal and social autopsy (VASA) procedures in a population-based household survey across Pakistan. Methods: We used a household survey based on the Pakistan National Nutrition Survey sampling frame, which covered 115 600 households in both urban and rural areas. We identified 3880 neonatal and post-neonatal under-five deaths within the three years prior to the survey. The VASA interviews were conducted in households where deaths were reported. We determined the causes of death using the computerised InterVA-5, InSilicoVA, and Expert Algorithm VA methods and the physician-certified VASA method, utilising thorough reviews by verbal autopsy-trained paediatric and obstetric physicians. Results: Neonatal mortality was estimated at 39.8 per 1000 live births (95% confidence interval (CI) = 39.3-40.3), with higher rates in rural (40.8; 95% CI = 40.2-41.4) compared to urban areas (37.3; 95% CI = 36.5-38.1). Post-neonatal under-five mortality was 35.9 per 1000 live births (95% CI = 35.4-36.4) and was also higher in rural (36.8; 95% CI = 36.2-37.4) than in urban areas (33.6; 95% CI = 32.6-34.5). The major causes of neonatal death included preterm birth complications, birth asphyxia, and infectious diseases. For post-neonatal under-five mortality, the leading causes were infectious diseases, diarrheal disorders, and pneumonia. Conclusions: Our findings highlight the persistent burden and disparities in neonatal and under-five mortality across urban and rural areas in Pakistan. Targeted interventions are essential to address these preventable deaths and reduce mortality rates in high-risk populations.