Sex inequality in under-five deaths and associated factors in low and middle-income countries: a Fairlie decomposition analysis

Abstract

Background There exist sex disparities in the burden of Under-five deaths (U5D) with a higher prevalence among male children. Factors explaining this inequality remain unexplored in Low-and Medium-Income Countries (LMIC). This study quantified the contributions of the individual- and neighborhood-level factors to sex inequalities in U5D in LMIC. Methods Demographic and Health Survey datasets (2010-2018) of 856,987 under-five children nested in 66,495 neighborhoods across 59 LMIC were analyzed. The outcome variable was U5D. The main group variable was the sex of the child while individual-level and neighborhood-level factors were the explanatory variables. Fairlie decomposition analysis was used to quantify the contributions of explanatory factors to the male-female inequalities in U5D at p<0.05. Results Overall weighted prevalence of U5D was 51/1000 children, 55 among males and 48 among females (p<0.001). Higher prevalence of U5D was recorded among male children in all countries except Liberia, Kyrgyz Republic, Bangladesh, Nepal, Armenia, Turkey and Papua New Guinea. Pro-female inequality was however not significant in any country. Of the 59 countries, 25 had statistically significant pro-male inequality. Different factors contributed to the sex inequality in U5D in different countries including birth order, birth weight, birth interval and multiple births. Conclusions There were sex inequalities in the U5D in LMIC with prominent pro-male-inequality in many countries. Interventions targeted towards the improvement of the health system that will, in turn, prevent preterm delivery and improve management of prematurity and early childhood infection (which are selective threats to the male child survival) are urgently required to address this inequality.

Factors contributing to household wealth inequality in under-five deaths in low- and middle-income countries: decomposition analysis

“…The characteristics of households include household's head gender (female/male), access to the media (captured using ownership or access to television, newspaper or radio, at least of these), drinking water sources (either improved/unimproved), toilet type (either improved/unimproved), cooking fuel (clean fuel/biomass), and housing materials (either improved/unimproved) [ 28 – 30 ], and, locations where mothers live (rural or urban). The categorizations of drinking water sources, housing materials, toilet type and cooking fuel as improved or not have been reported in previous studies [ 18 – 20 , 28 – 35 ].…”

“…The dependent variable is U5D, which is defined as deaths in the first five years of life among live births [ 18 – 20 ]. It is defined as death occurring between the ages of 0 and 59 months after birth [ 21 ].…”

“…The “neighbourhood” is the clustering of children as used in the sampling frames for the surveys. The DHS referred to “cluster” as a common geographical area that contains people that share similar contextual factors [ 15 , 16 , 18 ]. Children in the same cluster were referred to as "neighbours."…”

“…A random-effects meta-analysis was used based on the assumption that each trial calculates a study-specific actual effect. Using the "metabin" tool in R, the meta-analysis was carried out by identifying the summary measure (SM) as risk difference (RD), the number of fatalities in poor and non-poor households, and the total number of participants for each country, stratified by regions [ 18 ]. Scatter and ordered balloon charts were used to show the distributions of the RDs viz-a-viz the prevalence of U5Ds in each country in Figs.…”

“…3 and 4 . We defined pro-poor inequality as situations in which the RD in U5D is significantly lower among children from poor households than those from non-poor households and pro-non-poor inequality as situations in which the RD in U5D is significantly higher among children children from poor poor households than those from non-poor households [ 18 , 19 ]. The countries formed 3 groups based on the RDs: countries with pro-poor, insignificant and pro-non-poor inequalities.…”