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Determinants of neonatal, post-neonatal and child mortality in Afghanistan using frailty models



Afghanistan has one of the highest under-five mortality rates in South Asia, 70.4 per 1000 live births. Determinants need to be identified to reduce this rate. Knowledge of the existence of familial and community frailty will also assist in the reduction of under-five mortality.


The 2015 Afghanistan Demographic Health Survey, including 32,712 live births, was analysed. Under-five mortality was disaggregated into neonatal, post-neonatal and child mortality and piecewise traditional Cox proportional hazard, variance-corrected and frailty models were developed. All the models identified determinants and the two frailty models examined the existence of familial and community frailty for each age group.


There was statistically significant evidence of community frailty. Breastfeeding status was a highly significant determinant under univariable and multivariable analysis for neonatal and post-neonatal mortality. Post-neonates of employed mothers also experienced increased mortality, particularly those whose mother worked in agriculture where the hazard ratio was 2.77 (95% CI 2.10, 3.65). Birth order 5+ was associated with increased mortality for all three age groups.


The Afghanistan Ministry of Public Health should identify frail communities. Support, such as daycare facilities, should be provided and early initiation of breastfeeding and breastfeeding throughout the post-neonatal period should also be encouraged.


  • The study identified determinants of neonatal, post-neonatal and child mortality.

  • The study also established the presence of community frailty with respect to under-five mortality in Afghanistan.

  • The study shows that the association of not breastfeeding and mortality is more acute in the early neonatal age group and it extends into the post-neonatal age group.

  • The study identified the association of high birth order and mortality in the neonatal, post-neonatal and child age groups in Afghanistan.

  • Policies should be implemented that encourage early initiation of breastfeeding to continue throughout the post-neonatal period and support for vulnerable families should be provided.

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  1. World Health Organisation. Global Health Observatory Data—Explore a World of Health Data. Child Mortality and Causes of Death. (2018).

  2. Chowdhury, A. H. Determinants of under-five mortality in Bangladesh. Open J. Stat. 03:03, 213–219 (2013).

    Article  Google Scholar 

  3. Sohail, H. & Neupane, S. Prevalence of and factors associated with under-5 mortality in South Asia. Int. Health 11:02, 119–127 (2018).

    Google Scholar 

  4. Khan, J. R. & Awan, N. A comprehensive analysis on child mortality and its determinants in Bangladesh using frailty models. Arch. Public Health 75:1, 75 (2017).

    Article  Google Scholar 

  5. World Bank| Data. Mortality Rates, Neonatal (Per 1,000 Live Births)—Afghanistan. (2020).

  6. Kibria, G. M. A. et al. Determinants of early neonatal mortality in Afghanistan: an analysis of the demographic and health survey 2015. Global. Health 14:1, 47 (2018).

    Article  Google Scholar 

  7. Afghanistan Demographic Health Survey. (2015).

  8. Therneau, T. M. CRAN—Package Survival. Survival: Survival Analysis. (2020).

  9. Ezell, M. E., Land, K. C. & Cohen, L. E. Modeling multiple failure time data: a survey of variance-corrected proportional hazards models with empirical applications to arrest data. Sociol. Methodol. 33:1, 111–167 (2003).

    Article  Google Scholar 

  10. Cox, D. R. Regression models and life-tables. J. R. Stat. Soc. Ser. B Methodol. 34:2, 187–202 (1972).

    Google Scholar 

  11. Mani, K. Determinants of under-five mortality in rural empowered action group states in India: an application of Cox frailty model. Int. J. MCH AIDS 1, 60–72 (2012).

    Article  Google Scholar 

  12. Duchateau, L., & Janssen, P. The Frailty Model (Statistics for Biology and Health), 2008th edn (Springer, 2007).

  13. Hougaard, P. in Analysis of Multivariate Survival Data. Statistics for Biology and Health (eds Dietz, K., Gail, M., Krickeberg, K., Tsiatis, A., & Samet, J.) (Springer, 2000).

  14. Klein, J. P. Semiparametric estimation of random effects using the Cox model based on the EM algorithm. Biometrics 48:3, 795 (1992).

    Article  Google Scholar 

  15. Parner, E. Asymptotic theory for the correlated gamma-frailty model. Ann. Stat. 26:1, 183–214 (1998).

    Google Scholar 

  16. Therneau, T. M., Grambsch, P. M. & Pankratz, V. S. Penalized survival models and frailty. J. Comput. Graph. Stat. 12:1, 156–175 (2003).

    Article  Google Scholar 

  17. Gutierrez, R. G. Parametric frailty and shared frailty survival models. Stata J.: Promoting Commun. Stat. Stata 2:1, 22–44 (2002).

    Article  Google Scholar 

  18. Mullany, L. C. et al. Breast-feeding patterns, time to initiation, and mortality risk among newborns in southern Nepal. J. Nutr. 138:3, 599–603 (2008).

    Article  Google Scholar 

  19. Chen, A. & Rogan, W. J. Breastfeeding and the risk of postneonatal death in the United States. Pediatrics 113:5, e435–e439 (2004).

    Article  Google Scholar 

  20. Kozuki, N. & Walker, N. Exploring the association between short/long preceding birth intervals and child mortality: using reference birth interval children of the same mother as comparison. BMC Public Health 13(Suppl 3), S6 (2013).

    Article  Google Scholar 

  21. Neal, S., Channon, A. A. & Chintsanya, J. The impact of young maternal age at birth on neonatal mortality: evidence from 45 low and middle income countries. PLoS ONE 13:5, e0195731 (2018).

    Article  Google Scholar 

  22. Blanc, A. N. & Wardlaw, T. Monitoring low birth weight: an evaluation of International estimates and an updated estimation procedure. Bull. World Health Organ. 83, 178–185 (2005).

    PubMed  PubMed Central  Google Scholar 

  23. Nisar, Y. B. & Dibley, M. J. Determinants of neonatal mortality in Pakistan: secondary analysis of Pakistan Demographic and Health Survey 2006–07. BMC Public Health 14, 663 (2014).

    Article  Google Scholar 

  24. Sawyer, C. C. Child mortality estimation: estimating sex differences in childhood mortality since the 1970s. PLoS Med. 9:8, e1001287 (2012).

    Article  Google Scholar 

  25. Rasooly, M. H. et al. Success in reducing maternal and child mortality in Afghanistan. Glob. Public Health 9(Suppl 1), S29–S42 (2014).

    Article  Google Scholar 

  26. Siahanidou, T. et al. Disparities of infant and neonatal mortality trends in Greece during the years of economic crisis by ethnicity, place of residence and human development index: a nationwide population study. BMJ Open 9:8, e025287 (2019).

    Article  Google Scholar 

  27. Singh, R. & Tripathi, V. Maternal factors contributing to under-five mortality at birth order 1 to 5 in India: a comprehensive multivariate study. SpringerPlus 2:1, 284 (2013).

    Article  Google Scholar 

  28. Gebretsadik, S. & Gabreyohannes, E. Determinants of under-five mortality in high mortality regions of ethiopia: an analysis of the 2011 Ethiopia Demographic and Health Survey Data. Int. J. Popul. Res. 2, 1–7 (2016).

    Google Scholar 

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The research would not have been possible were it not for the assistance from my son, Dr. Ian Forde II, with the acquisition and download of the statistical software used in the analysis. All authors have met the Pediatric Research authorship requirement. Their contributions are listed below. I.A.F. contributed to the conception and design, acquisition of data, analysis and interpretation of data; drafting the article or revising it critically for important intellectual content; and the final approval of the version submitted for publication. V.T. contributed to the conception and design and interpretation of data; drafting the article or revising it critically for important intellectual content and gave final approval of the version submitted for publication. The study was self-funded.

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Forde, I.A., Tripathi, V. Determinants of neonatal, post-neonatal and child mortality in Afghanistan using frailty models. Pediatr Res 91, 991–1000 (2022).

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