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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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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 (2021).

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