Urban-rural disparity and urban population growth: A multilevel analysis of under-5 mortality in 30 sub-Saharan African countries

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Objectives:To assess whether country-level urban population growth is associated with the magnitude of the urban-rural disparity in under-five mortality (U5M) using ecologic and multilevel analyses.Methods:We used data from 2010 to 2015 Demographic and Health Surveys and World Bank data from 30 sub-Saharan African countries (n = 411,054 women). Country-level linear regressions determined associations between urban population growth and economic growth between 2005 and 2010 on U5M risk differences. Multilevel logistic regression models were used to determine the impact of urban population growth on the urban advantage in U5M, adjusting for child and maternal factors.Results:Countries with greater urban population growth and low economic growth had greater disparities in U5M between urban and rural areas. After adjusting for known U5M risk factors in multilevel analyses, interactions between country-level urban population growth and urbanicity were identified.Conclusions:Continued efforts to evaluate and address disparities in child mortality outcomes in sub-Saharan Africa should acknowledge urbanicity in context, as well as socioeconomic and geographic realities of families, mothers and children. Low-resource, demographically shifting environments require novel strategies to decrease child mortality.HighlightsSub-Saharan Africa has the highest under-5 mortality and urban population growth.Historically, under-5 mortality rates have been greater in rural areas.In sub-Saharan Africa, the historical urban advantage in child survival continues.Increased urban population growth is associated with larger urban-rural disparities.Individual and family level factors do not explain this association.

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