title: Sources of variation in under-5 mortality across sub-Saharan Africa: a spatial analysis.
abstract: Detailed spatial understanding of levels and trends in under-5 mortality is needed to improve the targeting of interventions to the areas of highest need, and to understand the sources of variation in mortality. To improve this understanding, we analysed local-level information on child mortality across sub-Saharan Africa between 1980-2010.
  
  
  
  We used data from 82 Demographic and Health Surveys in 28 sub-Saharan African countries, including the location and timing of 3·24 million childbirths and 393 685 deaths, to develop high-resolution spatial maps of under-5 mortality in the 1980s, 1990s, and 2000s. These estimates were at a resolution of 0·1 degree latitude by 0·1 degree longitude (roughly 10 km × 10 km). We then analysed this spatial information to distinguish within-country versus between-country sources of variation in mortality, to examine the extent to which declines in mortality have been accompanied by convergence in the distribution of mortality, and to study localised drivers of mortality differences, including temperature, malaria burden, and conflict.
  
  
  
  In our sample of sub-Saharan African countries from the 1980s to the 2000s, within-country differences in under-5 mortality accounted for 74-78% of overall variation in under-5 mortality across space and over time. Mortality differed significantly across only 8-15% of country borders, supporting the role of local, rather than national, factors in driving mortality patterns. We found that by the end of the study period, 23% of the eligible children in the study countries continue to live in mortality hotspots-areas where, if current trends continue, the Sustainable Developent Goals mortality targets will not be met. In multivariate analysis, within-country mortality levels at each pixel were significantly related to local temperature, malaria burden, and recent history of conflict.
  
  
  
  Our findings suggest that sub-national determinants explain a greater portion of under-5 mortality than do country-level characteristics. Sub-national measures of child mortality could provide a more accurate, and potentially more actionable, portrayal of where and why children are still dying than can national statistics.
  
  
  
  The Stanford Woods Institute for the Environment.
authors: Department of Earth System Science, Stanford University, Stanford, CA, USA; Center on Food Security and the Environment, Stanford University, Stanford, CA, USA; National Bureau of Economic Research, Cambridge, MA, USA.
authors: Marshall
authors: M
authors: Burke
authors: Department of Earth System Science, Stanford University, Stanford, CA, USA.
authors: Sam
authors: S
authors: Heft-Neal
authors: Division of General Medical Disciplines, Center for Health Policy, Stanford University, Stanford, CA, USA; Center for Primary Care and Outcomes Research, Stanford University, Stanford, CA, USA. Electronic address: ebd@stanford.edu.
authors: Eran
authors: E
authors: Bendavid
mesh_terms: D017954:Africa South of the Sahara / Q000453:epidemiology; D000068337:Armed Conflicts; D002648:Child; D046688:Child Mortality / Q000639:trends*; D006306:Health Surveys; D054625:Healthcare Disparities; D006801:Humans; D007223:Infant; D007226:Infant Mortality / Q000639:trends*; D008288:Malaria / Q000453:epidemiology; D062206:Spatial Analysis