Multi-level modeling of risk factors of under-five mortality in Ghana: evidence from the 2022 demographic and health survey

Ghana continues to face significant challenges in under-five mortality (U5M) despite initiatives such as the integrated Reproductive, Maternal, Newborn, Child, and Adolescent Health and Nutrition (RMNCAHN) policy framework and the National Health Insurance Scheme. To determine the regional distribution and risk factors for U5M in Ghana using the 2022 Ghana Demographic and Health Survey (GDHS). This was a population-based, cross-sectional secondary data analysis of the 2022 GDHS. The analyses included 8580 weighted children. The outcome variable was under-five mortality coded as “1” for death and “0” for survival. Multilevel logistic regression models were employed to investigate the risk factors of under-five mortality. The receiver operating characteristic (ROC) curve and area under the curve (AUC), Akaike Information Criterion (AIC), and Bayesian Information Criterion (BIC) were used to assess model discrimination and goodness-of-fit. Statistical significance was set at p < 0.05. The study found 266 (3.1%) (95% confidence interval (C.I): 2.8%–3.5%) deaths among children under 5 with a mortality rate of 31/1000 births. The regional distribution of the U5M rate was highest in the Oti, Western North, Volta, Ahafo, and Greater Accra regions, with significant variations observed across multiple administrative areas. In the regression analysis, children of mothers with lower levels of education showed varying associations with under-5 mortality. Those with higher antenatal visit frequencies (e.g., 8 + visits) in model 2 (AOR = 4.38, 95% CI 1.69–11.37) and the full combined model (AOR = 4.38, 95% CI 1.69–11.37) showed significantly higher odds of U5M, while parity showed a strong positive association (AOR = 8.05, 95% CI 4.87–13.32) rather than being protective. There was a residual ICC of 0.178. Maternal education, antenatal care utilization, and regional disparities were key factors associated with child mortality in Ghana. Governments should improve the quality, affordability, and accessibility of education and Antenatal Care Services to reduce child mortality and advance progress toward the Sustainable Development Goals.