Multilevel Survival Modelling of Neonatal Mortality under Some Prognostic Factors in Uttar Pradesh
Multilevel Survival Modelling of Neonatal Mortality
,
Abstract
Introduction: Neonatal Mortality, a critical indicator of country’s socio-economic and healthcare status, remains a significant global concern. While India has made significant progress in reducing child mortality over the past decades, further improvements are needed in reducing newborn mortality. The traditional survival models like cox proportional hazard model assume independence among individual, whereas multilevel survival models integrate hierarchical structures, provide more accurate insights into mortality trends and determinants. This study identifies significant prognostic determinants of neonatal mortality in Uttar Pradesh, India, using data from NFHS-V (2019-2021) and explore regional and community-level effects with the multilevel parametric models.
Methods: The multilevel mixed-effects Weibull and exponential parametric survival models were applied, incorporating both individual and community-level factors. Primary Sampling Units (PSUs) and districts were treated as hierarchical levels. Akaike Information Criteria (AIC) was used to determine the best fitted model.
Result: This study highlighted the complex, multi-level determinants of neonatal mortality in Uttar Pradesh. The multilevel Weibull mixed-effects model provided a better fit compared to individual-level and Exponential models. The results determine the significant impact of social inequalities, the crucial role of maternal education, place of delivery and the importance of newborn birth weight and size in determining neonatal outcomes.
Conclusion: The study recommends that efforts to reduce neonatal mortality should address not only individual-level risk factors but also community-level disparities in healthcare access and quality.
1. WHO. Newborn mortality: World Health Organization; 2024 [WHO]. Available from: https://www.who.int/news-room/fact-sheets/detail/newborn-mortality.
2. UNICEF Data:Neonatal Mortality New York: UNICEF; 2024 [Available from: Available from: https://data.unicef.org/topic/child-survival/neonatal-mortality/.
3. Duke T. Levels and trends in child mortality estimation. Archives of Disease in Childhood. 2024;109(8):620–1.
4. Office of the Registrar General & Census Commissioner, India. Sample Registration System (SRS) Statistical Report 2020. New Delhi: Government of India; 2022.
5. Government of India, Ministry of Health and Family Welfare. Compendium of Fact Sheets India
and 14 States/UTs (Phase-II): National Family Health Survey (NFHS-5) 2019-21. New Delhi: MoHFW; 2021.
6. National Health Systems Resource Centre (NHSRC). Health Dossier 2021: Reflections on Key Health Indicators – Uttar Pradesh New Delhi: NHSRC; 2021.
7. Jana A, Saha UR, Reshmi RS, Muhammad T. Relationship between low birth weight and infant mortality: evidence from National Family Health Survey 2019-21, India. Archives of Public Health. 2023;81(1).
8. Y G, S B. Survival Analysis of Under-Five Mortality of Children and its Associated Risk Factors in Ethiopia. Journal of Biosensors & Bioelectronics. 2016;7(3).
9. Saroj RK, Murthy KHHVSSN, Kumar M, Singh R, Kumar A. Survival Parametric Models to
J BIOSTAT EPIDEMIOL. VOL. 11, NO. 4, 2025 471
Mishra S et al. Multilevel Survival Modelling of Neonatal Mortality under Some Prognostic Factors in Uttar Pradesh Estimate the Factors of Under-Five Child Mortality. Journal of Health Research and Reviews. 2019;6(2):82–8.
10. Ayiko R, Antai D, Kulane A. Trends and determinants of under-five mortality in Uganda. East African journal of public health. 2009;6 2:136–40.
11. Pandey A, Sharma R. Neonatal Deaths in Empowered Action Group States: Multilevel Modeling to
Study the within District Education Effect on Neonatal Survival. International Journal of Scientific Research. 2022:54–7.
12. Kumar M, Patel K. Differential and determinants of neonatal mortality: A comparative study in Northern and Southern Regions of India. Indian Journal of Community Medicine. 2021;46(3).
13. Moise IK, Bora JK, Saikia N. Neonatal and under-five mortality rate in Indian districts with
reference to Sustainable Development Goal 3: An analysis of the National Family Health Survey of India (NFHS), 2015–2016. Plos One. 2018;13(7).
14. Jaiswal AK, Alagarajan M, Meitei WB. Survival among children under-five in India: a parametric multilevel survival approach. BMC Public Health. 2024;24(1).
15. The DHS Program [Internet]. 2024. Available from: Available from: https://dhsprogram.com/data/available-datasets.cfm.
16. Patel N, Olickal JJ. Maternal and child factors of under-five mortality in India. Findings from NFHS-4. Clinical Epidemiology and Global Health. 2021;12.
17. Patel AB, Meleth S, Pasha O, Goudar SS, Esamai F, Garces AL, et al. Impact of exposure to cooking fuels on stillbirths, perinatal, very early and late neonatal mortality - a multicenter prospective
cohort study in rural communities in India, Pakistan, Kenya, Zambia and Guatemala. Maternal Health, Neonatology and Perinatology. 2015;1(1).
18. Rutstein SO JK. The DHS Wealth Index. DHS Comparative Reports No. 6. Calverton: ORC Macro. 2004.
19. Cleary-Goldman J, Malone FD, Vidaver J, Ball RH, Nyberg DA, Comstock CH, et al. Impact of Maternal Age on Obstetric Outcome. Obstetrics & Gynecology. 2005;105(5, Part 1):983–90.
20. Oyato B, Zakir H, Hussein D, Lemma T, Awol M. Time to Death and Its Predictors Among Infants in Ethiopia: Multilevel Mixed-Effects Parametric Survival Analysis Using the 2019 Ethiopian Mini Demographic Health Survey. Pediatric Health, Medicine and Therapeutics. 2023; Volume 14:169–83.
21. Andrade C. Survival Analysis, Kaplan-Meier Curves, and Cox Regression: Basic Concepts. Indian Journal of Psychological Medicine. 2023;45(4):434–5.
22. StataCorp. Stata Statistical Software: Release 13.1 [Computer program]. College Station (TX): StataCorp LLC; 2013.
23. Zhang Z. Parametric regression model for survival data: Weibull regression model as an example. Annals of Translational Medicine. 2016;4(24):484–.
24. Oyato B, Zakir H, Hussein D, Lemma T, Awol M. Time to Death and Its Predictors Among Infants in Ethiopia: Multilevel Mixed-Effects Parametric Survival Analysis Using the 2019 Ethiopian Mini Demographic Health Survey. Pediatric Health, Medicine and Therapeutics. 2023;Volume 14:169–83.
25. Crowther MJ. Multilevel mixed-effects parametric survival analysis: Estimation, simulation, and
application. The Stata Journal: Promoting communications on statistics and Stata. 2019;19(4):931 49.
26. Tesema GA, Teshale AB, Tessema ZT. Incidence and predictors of under-five mortality in East Africa using multilevel Weibull regression modeling. Archives of Public Health. 2021;79(1).
27. Taketomi N, Yamamoto K, Chesneau C, Emura T. Parametric Distributions for Survival and Reliability Analyses, a Review and Historical Sketch. Mathematics. 2022;10(20).
28. Zhan Y, Fagbamigbe AF, Norrman E, Bergh C, Wennerholm U-B, Petzold M. Comparison of the performances of survival analysis regression models for analysis of conception modes and risk of type-1 diabetes among 1985–2015 Swedish birth cohort. Plos One. 2021;16(6).
29. Masoomehnikbakht KFVa. APPLICATION REMLMODEL AND DETERMINING CUT OFF OF ICC BY MULTI-LEVEL MODEL BASED ON MARKOV CHAINS SIMULATION IN HEALTH. Indian Journal of Fundamental and Applied Life Sciences. 2015;5(S2):1432–48/Vajargah and Nikbakht.
30. Cavanaugh JE, Neath AA. The Akaike information criterion: Background, derivation, properties, application, interpretation, and refinements. WIREs Computational Statistics. 2019;11(3).
31. Lewis F, Butler A, Gilbert L. A unified approach to model selection using the likelihood ratio test. Methods in Ecology and Evolution. 2010;2(2):155–62.
32. SSubramanian SV, Kumar A, Pullum TW, Ambade M, Rajpal S, Kim R. Early-Neonatal, Late Neonatal, Postneonatal, and Child Mortality Rates Across India, 1993-2021. JAMA Network Open. 2024;7(5).
33. Goudar SS, Goco N, Somannavar MS, Kavi A, Vernekar SS, Tshefu A, et al. Institutional deliveries and stillbirth and neonatal mortality in the Global Network's Maternal and Newborn Health Registry. Reproductive Health. 2020;17(S3).
34. A.U C, S.O O, V.E J-D, Li B. A Multilevel Hazards Model for Child Mortality In Nigeria. Journal of Child and Adolescent Psychiatry. 2019;1(1):9–23.
2. UNICEF Data:Neonatal Mortality New York: UNICEF; 2024 [Available from: Available from: https://data.unicef.org/topic/child-survival/neonatal-mortality/.
3. Duke T. Levels and trends in child mortality estimation. Archives of Disease in Childhood. 2024;109(8):620–1.
4. Office of the Registrar General & Census Commissioner, India. Sample Registration System (SRS) Statistical Report 2020. New Delhi: Government of India; 2022.
5. Government of India, Ministry of Health and Family Welfare. Compendium of Fact Sheets India
and 14 States/UTs (Phase-II): National Family Health Survey (NFHS-5) 2019-21. New Delhi: MoHFW; 2021.
6. National Health Systems Resource Centre (NHSRC). Health Dossier 2021: Reflections on Key Health Indicators – Uttar Pradesh New Delhi: NHSRC; 2021.
7. Jana A, Saha UR, Reshmi RS, Muhammad T. Relationship between low birth weight and infant mortality: evidence from National Family Health Survey 2019-21, India. Archives of Public Health. 2023;81(1).
8. Y G, S B. Survival Analysis of Under-Five Mortality of Children and its Associated Risk Factors in Ethiopia. Journal of Biosensors & Bioelectronics. 2016;7(3).
9. Saroj RK, Murthy KHHVSSN, Kumar M, Singh R, Kumar A. Survival Parametric Models to
J BIOSTAT EPIDEMIOL. VOL. 11, NO. 4, 2025 471
Mishra S et al. Multilevel Survival Modelling of Neonatal Mortality under Some Prognostic Factors in Uttar Pradesh Estimate the Factors of Under-Five Child Mortality. Journal of Health Research and Reviews. 2019;6(2):82–8.
10. Ayiko R, Antai D, Kulane A. Trends and determinants of under-five mortality in Uganda. East African journal of public health. 2009;6 2:136–40.
11. Pandey A, Sharma R. Neonatal Deaths in Empowered Action Group States: Multilevel Modeling to
Study the within District Education Effect on Neonatal Survival. International Journal of Scientific Research. 2022:54–7.
12. Kumar M, Patel K. Differential and determinants of neonatal mortality: A comparative study in Northern and Southern Regions of India. Indian Journal of Community Medicine. 2021;46(3).
13. Moise IK, Bora JK, Saikia N. Neonatal and under-five mortality rate in Indian districts with
reference to Sustainable Development Goal 3: An analysis of the National Family Health Survey of India (NFHS), 2015–2016. Plos One. 2018;13(7).
14. Jaiswal AK, Alagarajan M, Meitei WB. Survival among children under-five in India: a parametric multilevel survival approach. BMC Public Health. 2024;24(1).
15. The DHS Program [Internet]. 2024. Available from: Available from: https://dhsprogram.com/data/available-datasets.cfm.
16. Patel N, Olickal JJ. Maternal and child factors of under-five mortality in India. Findings from NFHS-4. Clinical Epidemiology and Global Health. 2021;12.
17. Patel AB, Meleth S, Pasha O, Goudar SS, Esamai F, Garces AL, et al. Impact of exposure to cooking fuels on stillbirths, perinatal, very early and late neonatal mortality - a multicenter prospective
cohort study in rural communities in India, Pakistan, Kenya, Zambia and Guatemala. Maternal Health, Neonatology and Perinatology. 2015;1(1).
18. Rutstein SO JK. The DHS Wealth Index. DHS Comparative Reports No. 6. Calverton: ORC Macro. 2004.
19. Cleary-Goldman J, Malone FD, Vidaver J, Ball RH, Nyberg DA, Comstock CH, et al. Impact of Maternal Age on Obstetric Outcome. Obstetrics & Gynecology. 2005;105(5, Part 1):983–90.
20. Oyato B, Zakir H, Hussein D, Lemma T, Awol M. Time to Death and Its Predictors Among Infants in Ethiopia: Multilevel Mixed-Effects Parametric Survival Analysis Using the 2019 Ethiopian Mini Demographic Health Survey. Pediatric Health, Medicine and Therapeutics. 2023; Volume 14:169–83.
21. Andrade C. Survival Analysis, Kaplan-Meier Curves, and Cox Regression: Basic Concepts. Indian Journal of Psychological Medicine. 2023;45(4):434–5.
22. StataCorp. Stata Statistical Software: Release 13.1 [Computer program]. College Station (TX): StataCorp LLC; 2013.
23. Zhang Z. Parametric regression model for survival data: Weibull regression model as an example. Annals of Translational Medicine. 2016;4(24):484–.
24. Oyato B, Zakir H, Hussein D, Lemma T, Awol M. Time to Death and Its Predictors Among Infants in Ethiopia: Multilevel Mixed-Effects Parametric Survival Analysis Using the 2019 Ethiopian Mini Demographic Health Survey. Pediatric Health, Medicine and Therapeutics. 2023;Volume 14:169–83.
25. Crowther MJ. Multilevel mixed-effects parametric survival analysis: Estimation, simulation, and
application. The Stata Journal: Promoting communications on statistics and Stata. 2019;19(4):931 49.
26. Tesema GA, Teshale AB, Tessema ZT. Incidence and predictors of under-five mortality in East Africa using multilevel Weibull regression modeling. Archives of Public Health. 2021;79(1).
27. Taketomi N, Yamamoto K, Chesneau C, Emura T. Parametric Distributions for Survival and Reliability Analyses, a Review and Historical Sketch. Mathematics. 2022;10(20).
28. Zhan Y, Fagbamigbe AF, Norrman E, Bergh C, Wennerholm U-B, Petzold M. Comparison of the performances of survival analysis regression models for analysis of conception modes and risk of type-1 diabetes among 1985–2015 Swedish birth cohort. Plos One. 2021;16(6).
29. Masoomehnikbakht KFVa. APPLICATION REMLMODEL AND DETERMINING CUT OFF OF ICC BY MULTI-LEVEL MODEL BASED ON MARKOV CHAINS SIMULATION IN HEALTH. Indian Journal of Fundamental and Applied Life Sciences. 2015;5(S2):1432–48/Vajargah and Nikbakht.
30. Cavanaugh JE, Neath AA. The Akaike information criterion: Background, derivation, properties, application, interpretation, and refinements. WIREs Computational Statistics. 2019;11(3).
31. Lewis F, Butler A, Gilbert L. A unified approach to model selection using the likelihood ratio test. Methods in Ecology and Evolution. 2010;2(2):155–62.
32. SSubramanian SV, Kumar A, Pullum TW, Ambade M, Rajpal S, Kim R. Early-Neonatal, Late Neonatal, Postneonatal, and Child Mortality Rates Across India, 1993-2021. JAMA Network Open. 2024;7(5).
33. Goudar SS, Goco N, Somannavar MS, Kavi A, Vernekar SS, Tshefu A, et al. Institutional deliveries and stillbirth and neonatal mortality in the Global Network's Maternal and Newborn Health Registry. Reproductive Health. 2020;17(S3).
34. A.U C, S.O O, V.E J-D, Li B. A Multilevel Hazards Model for Child Mortality In Nigeria. Journal of Child and Adolescent Psychiatry. 2019;1(1):9–23.
| Files | ||
| Issue | Vol 11 No 4 (2025) | |
| Section | Original Article(s) | |
| DOI | https://doi.org/10.18502/jbe.v11i4.22521 | |
| Keywords | ||
| Multilevel Weibull mixed effect models Random effect Akaike Information Criteria (AIC) Neonatal Mortality | ||
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How to Cite
1.
Jaiswal S, Mishra S. Multilevel Survival Modelling of Neonatal Mortality under Some Prognostic Factors in Uttar Pradesh. J Biostat Epidemiol. 2026;11(4):458-474.
