Survival analysis of under-five mortality predictors: evidence from the 2011 and 2022/23 mozambique demographic and health surveys

Abstract Background Under-five mortality (U5M) is a critical indicator for assessing the overall health status of a population. Mozambique faces challenges in this area, and understanding risk factors is essential for developing effective interventions. This study aimed to identify predictors of under-five mortality through survival analysis among children in Mozambique. Methods This study used data from the 2011 (n = 7,647) and 2022/23 (n = 6,783) Mozambique Demographic and Health Surveys (MDHS), nationally representative surveys based on a multistage, stratified cluster sampling design. Under-five mortality was defined as the death of a live-born child before 60 months of age. Kaplan-Meier methods and Cox proportional hazards regression were used to estimate survival and identify predictors of mortality. Results In 2011, 5.7% of children died before reaching age five and 4.7% within the first year of life. By 2022/23, these proportions had declined to 3.7% and 3.0%, respectively. A lower risk of mortality was observed among female children (2022/23: AHR = 0.56; 95% CI: 0.35-0.90), those living in households with five or more members (2011: AHR = 0.57; 95% CI: 0.43-0.76), and those in households with three or more children under five years of age (2011: AHR = 0.33; 95% CI: 0.18-0.61; 2022/23: AHR = 0.28; 95% CI: 0.13-0.61). In contrast, higher mortality risk was identified among children residing in urban areas (AHR = 1.42; 95% CI: 1.03-1.96), those reported to use bed nets for sleeping (2022/23: AHR = 2.39; 95% CI: 1.30-4.40), those with low birth weight (2011: AHR = 2.08; 95% CI: 1.30-3.33), and those delivered at home or outside public health facilities. Conclusion These findings highlight the importance of strengthening maternal education and increasing investment in health systems to reduce under-five mortality in Mozambique. Expanding resources for maternal, neonatal, and child health services, particularly prenatal and obstetric care, is essential to further improve child survival outcomes.