Factors associated with maternal-level under-five child death burden in Ethiopia

Ethiopia has made notable progress in reducing under-five mortality during the past two decades through expanded primary healthcare services and community-based health programs. However, child mortality remains a significant public health issue, and considerable disparities persist across regions and population groups. Identifying the determinants linked to under-five mortality is crucial for enhancing maternal and child health policies. This study examined factors associated with the number of under-five deaths among Ethiopian women using nationally representative survey data. This study used data from the 2019 Ethiopia Mini Demographic and Health Survey (2019 EMDHS), including 5,582 women aged 15–49 years with at least one live birth. The dependent variable was the count of under-five child deaths reported by each mother. The survey-weighted quasi-Poisson model was utilized. The analysis utilized sampling weights, clustering, and stratification to address the complex survey design. Incidence Rate Ratios (IRR) with 95% confidence intervals were utilized to measure the associations between explanatory variables and the frequency of under-five mortality per mother. Compared with the Tigray region, mothers residing in Gambela experienced the highest adjusted maternal-level under-five child death rates (IRR = 2.56, 95% CI 1.65–3.98, p < 0.001). And also high deaths observed in Somali (IRR = 2.16, 95% CI 1.40–3.32, p < 0.001), Dire Dawa (IRR = 2.09, 95% CI 1.25–3.50, p = 0.005), Benishangul-Gumuz (IRR = 1.96, 95% CI 1.25–3.06, p = 0.003), Amhara (IRR = 1.73, 95% CI 1.14–2.62, p = 0.011), Oromia (IRR = 1.58, 95% CI 1.05–2.38, p = 0.028), and SNNPR (IRR = 1.53, 95% CI 1.02–2.30, p = 0.038). Regional differences for Afar, Harari, and Addis Ababa were not statistically significant. Mothers with higher education had significantly lower maternal-level under-five child death rates than mothers with no formal education (IRR = 0.42, 95% CI 0.19–0.95, p = 0.036). In contrast, each one-year increase in maternal age at interview was associated with a 2.2% increase in the adjusted maternal-level under-five child death rates (IRR = 1.02, 95% CI 1.00–1.04, p = 0.016). Compared with mothers whose preceding birth interval was ≥ 36 months, mothers with birth intervals shorter than 24 months had 56% higher adjusted maternal-level under-five child death rates (IRR = 1.56, 95% CI 1.25–1.95, p < 0.001). Birth intervals of 24–35 months were not significantly associated with maternal-level under-five child death rates. Compared with home delivery, births occurring in other public facilities were associated with substantially higher adjusted maternal-level under-five child death rates (IRR = 5.13, 95% CI 1.55–17.00, p = 0.008). Conversely, delivery in a private hospital (IRR = 0.20, 95% CI 0.06–0.63, p = 0.006) and in an NGO facility (IRR = 0.36, 95% CI 0.24–0.56, p < 0.001) was associated with significantly lower maternal-level under-five child death rates than home delivery. Maternal-level under-five child death rates in Ethiopia remains strongly associated with regional disparities, maternal education, and reproductive factors, particularly maternal age and birth spacing. Strengthening equitable maternal and child health services, expanding access to maternal education, and promoting optimal birth spacing through reproductive health programs may contribute to lower maternal-level under-five child death rates and reduction of regional inequalities.