Spatial variability of child survival in Ethiopia: evidence from nationally representative surveys

In Ethiopia, under-five mortality remains unacceptably high and varied geographically across the country with the highest (125 death per 1000 live children) in the Afar region to the lowest (39 deaths per 1000 children) in Addis Ababa City Administration in 2016. Geographic variation is persistent in childhood undernutrition, where the prevalence of underweight was highest (36%) in the Afar region, whereas stunting (47%) and wasting (23%) were highest in the Amhara and Somali regions of the country, respectively. In addition, the prevalence of childhood anemia was highest in Somali region (83%), and lowest (42%) in the Amhara region. Therefore, this study attempted to explore the spatial pattern and clustering of childhood undernutrition, childhood anemia, and under-five mortality in the country.

The spatial analysis used the Ethiopia Demographic and Health Surveys (EDHS) data collected in 2011 and 2016 that provided geographic, demographic, and health information of children below the age of five and their mothers between 15 and 49 years old. The pooled data, consisting of 22,225 under-five children, was extracted and linked with the 2011 and 2016 DHS Shapefiles, and 596 EA (clusters) were matched to their respective regions. Moran's I and Getis-Ord Gi* statistics were employed to examine spatial patterns and clustering of childhood undernutrition, childhood anemia, and under-five mortality in the country.

The national pooled prevalence of childhood undernutrition and anemia stood at 48.6% and 55.1%, respectively, while 6.7% of children had died before age five (approximately one in every 14 children). Regionally, the highest undernutrition rates were recorded in Afar (61.6%) and Amhara (57.1%), while Addis Ababa had the lowest (21.1%). Anemia was most prevalent and highest in Somali (77.9%) and Afar (76.1%), and lowest in Amhara (39.1%). Under-five mortality was highest in Afar (8.6%) and Benishangul-Gumuz (8.3%), and lowest in Addis Ababa (3.3%). Spatial analysis showed significant clustering for all three indicators: undernutrition (Moran's I = 0.024), anemia (Moran's I = 0.029), and under-five mortality (Moran's I = 0.010), all with p < 0.001. Hotspots were concentrated in Afar, Somali, eastern Oromia, and Benishangul-Gumuz, while Addis Ababa and parts of SNNPR were cold spots.

The present study underscores the importance of spatial location specific child survival interventions targeted to reduce childhood anemia, undernutrition and under-five mortality. Therefore, child survival programs tailored to geographic location risk factors connected with childhood anemia, undernutrition and under-five mortality would be more efficient and effective in Ethiopia.