<p>Joint probability of the response variables.</p>

Background of the study

Child mortality remains a major public health issue in Ethiopia, with under-five mortality rates among the highest in sub-Saharan Africa. Despite efforts to improve maternal and child health, many women still give birth at home without skilled assistance, which has been associated with adverse maternal and child health outcomes. Therefore, this study aimed to investigate the association and determinants of home delivery and under-five mortality (U5M) using a multilevel bivariate modeling approach.

Methods

A cross-sectional study was conducted among 5,517 women with a birth history using data from the Ethiopian Mini Demographic and Health Survey (EMDHS) 2019. Data management and analysis were performed using STATA version 17 and R version 4.2.2. The chi-square test of association was used to examine the association between predictor and outcome variables, and multilevel bivariate analysis was conducted to identify significant factors associated with the outcome variables.

Results

Out of 5,517 women with birth history, 2,842 (51.5%) were delivered at home, and 269 (4.87%) reported experiencing at least one under-five child death. As shown in the joint and marginal probabilities of home delivery and U5M, there was a significant association (χ² = 3.83, P-value < 0.0001). The adjusted odds ratio (AOR = 2.19, 95% CI: 1.89–2.62) indicates that mothers who delivered at home had 2.19 times higher odds of experiencing at least one under-five child death than mothers who delivered in a health facility.

Conclusion

Overall, home delivery and U5M were significantly associated with a combination of individual, household, and community-level factors. Education, wealth, antenatal and postnatal care, and media exposure were associated with lower odds of both outcomes, while rural residence, too young or too old maternal age, and lower economic status were associated with higher odds. Regional disparities further indicate the need for targeted interventions. Expanding healthcare access in rural areas, improving female education, promoting antenatal and postnatal care, and increasing media-based health awareness campaigns may contribute to reducing the prevalence of home delivery and maternal experience of under-five child death in Ethiopia.