Research Article: Geographical variation in the association of child, maternal and household health interventions with under-five mortality in Burkina Faso

Date Published: July 1, 2019

Publisher: Public Library of Science

Author(s): Ourohiré Millogo, Jean Edouard Odilon Doamba, Ali Sié, Jürg Utzinger, Penelope Vounatsou, Benn Sartorius.


Over the past 15 years, scaling up of cost effective interventions resulted in a remarkable decline of under-five mortality rates (U5MR) in sub-Saharan Africa. However, the reduction shows considerable heterogeneity. We estimated the association of child, maternal, and household interventions with U5MR in Burkina Faso at national and subnational levels and identified the regions with least effective interventions.

Data on health-related interventions and U5MR were extracted from the Burkina Faso Demographic and Health Survey (DHS) 2010. Bayesian geostatistical proportional hazards models with a Weibull baseline hazard were fitted on the mortality outcome. Spatially varying coefficients were considered to assess the geographical variation in the association of the health interventions with U5MR. The analyses were adjusted for child, maternal, and household characteristics, as well as climatic and environmental factors.

The average U5MR was as high as 128 per 1000 ranging from 81 (region of Centre-Est) to 223 (region of Sahel). At national level, DPT3 immunization and baby post-natal check within 24 hours after birth had the most important association with U5MR (hazard rates ratio (HRR) = 0.89, 95% Bayesian credible interval (BCI): 0.86–0.98 and HRR = 0.89, 95% BCI: 0.86–0.92, respectively). At sub-national level, the most effective interventions are the skilled birth attendance, and improved drinking water, followed by baby post-natal check within 24 hours after birth, vitamin A supplementation, antenatal care visit and all-antigens immunization (including BCG, Polio3, DPT3, and measles immunization). Centre-Est, Sahel, and Sud-Ouest were the regions with the highest number of effective interventions. There was no intervention that had a statistically important association with child survival in the region of Hauts Bassins.

The geographical variation in the magnitude and statistical importance of the association between health interventions and U5MR raises the need to deliver and reinforce health interventions at a more granular level. Priority interventions are DPT3 immunization, skilled birth attendance, baby post-natal visits in the regions of Sud-Ouest, Sahel, and Hauts Bassins, respectively. Our methodology could be applied to other national surveys, as it allows an incisive, data-driven and specific decision-making approach to optimize the allocation of health interventions at subnational level.

Partial Text

Under-five mortality remains a major public health issue in sub-Saharan Africa, despite a remarkable decline during the Millennium Development Goal (MDG) era from 2000 to 2015 [1]. The under-5 mortality rate (U5MR) estimates in 2016 suggest that one in twelve children of sub-Saharan Africa did not reach their fifth birthday [2]. Pneumonia, preterm birth complications, intrapartum events, and diarrhoea constitute the main causes of under-5 deaths in sub-Saharan Africa [3]. Indirect factors related to child, maternal, family, community, and the environment are also strongly associated with under-5 mortality, and hence underlie theses direct causes [3–5]. Most of the direct and indirect causes are preventable. During the MDG era, facilitated by the commitment of donors, local governments, and other stakeholders cost-effective interventions were scaled up. The effects of the interventions show considerable spatial heterogeneity.

Our sample included 541 (94.3%) clusters and 13 505 (87.8%) children under the age of five years, after removing clusters with missing coordinates. In total, 1209 (9%) children died before their fifth birthday owing to an estimate for U5MR of 128 per 1000. The geographical distribution of U5MR is shown in Fig 1. The highest U5MRs were observed in the regions of Est, Sahel, and Sud-Ouest with respective U5MR of 172, 197, and 223 per 1000. The Centre-Est had the lowest rate of 81 per 1000.

This is the first study to assess geographical variation in the association of child, maternal and household health interventions with child survival in Burkina Faso at regional level, taking into account socio-demographics characteristics and climatic disparities. The geographical distribution of the coverage of the health interventions showed considerable heterogeneity. Interventions with the highest coverage (> 80%) are those related to child immunization and antenatal care visits. Skilled birth attendance, improved drinking water, and vitamin A supplementation had coverage of 60–80% at country level. The promotion of the above mentioned health interventions have history of several decades. Conversely, interventions with national coverage of less than 40% are those whose implementation was strengthened only the year 2000. These include treatment of malaria with ACTs, exclusive breastfeeding, and early breastfeeding after childbirth.