The enduring burden of short birth intervals on child survival: A 28-year trend analysis in Burkina Faso
Child survival has improved considerably over the past decades in sub-Saharan Africa, yet preventable risk factors such as closely spaced births continue to threaten progress, especially in fragile contexts. This study examines the association between interbirth intervals and under-five survival in Burkina Faso using data from five rounds of Demographic and Health Surveys conducted between 1993 and 2021. The study combines descriptive survival analysis (e.g., Kaplan–Meier curves, log-rank tests) with Cox proportional hazards models to estimate the adjusted association between interbirth intervals and under-five mortality, while controlling for maternal, child, household, and contextual characteristics. The results show that short interbirth intervals (<24 months) are consistently associated with excess mortality, following a markedly non-linear trajectory: the adjusted hazard ratio declines from 2.50 (95% confidence interval: 1.56–4.0) in 1993 to 1.49 (1.04–2.14) in 1998–1999 and 1.63 (1.27–2.1) in 2003, then rises to 1.97 (1.64–2.38) in 2010 and peaks at 3.20 (2.28–4.49) in 2021. In contrast, the protective advantage of long intervals (≥36 months), significant from 1998 to 2010, disappears in the most recent survey. These dynamics suggest that health system strengthening and expanded access to care have mitigated part of the vulnerability associated with closely spaced births, but that these gains remain fragile in the context of escalating security crisis and persistent socio-territorial inequalities. Over time, under-five survival appears increasingly shaped by socioeconomic (e.g., household wealth, maternal education), territorial (e.g., rural residence, conflict-affected regions), and biological factors (e.g., low birth weight, extreme maternal ages). In this context, the enduring burden of mortality linked to short interbirth intervals, particularly among poor rural households and adolescent mothers, calls for geographically and socially targeted family planning strategies, embedded within an integrated package of maternal and child health, nutrition, vaccination, and equitable access to quality healthcare services.
Adedini, S. A., Anjorin, S. S., Mobolaji, J. W., Okolie, E. A., & Yaya, S. (2024). Assessing Africa›s child survival gains and prospects for attaining SDG target on child mortality. PLOS Global Public Health, 4(7), e0003022. https://doi.org/10.1371/journal.pgph.0003022
Allison, P. D. (2010). Survival analysis using SAS: A practical guide (2nd ed.). SAS Institute. Accessed June 16, 2026. https://books.google.com/books/about/Survival_Analysis_ Using_SAS.html?id=RmbZ2y1KLwUC
Andriano, L., & Monden, C. W. S. (2019). The causal effect of maternal education on child mortality: Evidence from a quasi-experiment in Malawi and Uganda. Demography, 56(5), 1765–1790. https://doi.org/10.1007/s13524-019-00812-3
Black, R. E., Cousens, S., Johnson, H. L., Lawn, J. E., Rudan, I., Bassani, D. G., Jha, P., Campbell, H., Walker, C. F., Cibulskis, R., Eisele, T., Liu, L., & Mathers, C. (2010). Global, regional, and national causes of child mortality in 2008: A systematic analysis. The Lancet, 375(9730), 1969–1987. https://doi.org/10.1016/s0140-6736(10)60549-1
Bocquier, P. (1991). Les relations entre mortalité des enfants et espacement des naissances dans la banlieue de Dakar (Sénégal). Population (French Edition), 46(4), 813. https://doi.org/10.2307/1533297
Bongaarts, J., & Sinding, S. (2011). Population policy in transition in the developing world. Science, 333(6042), 574–576. https://doi.org/10.1126/science.1207558
Chekole, F. A., Tesfu, A. A., Beyene, F. Y., & Balcha, W. F. (2025). The effect of antenatal care on low birth weight and neonatal mortality: Protocol for umbrella review of meta-analysis. Journal of Health, Population and Nutrition, 44(1). https://doi.org/10.1186/s41043-025-00904-4
Clark, S., Kabiru, C. W., Laszlo, S., & Muthuri, S. (2019). The impact of childcare on poor urban women›s economic empowerment in Africa. Demography, 56(4), 1247–1272. https://doi.org/10.1007/s13524-019-00793-3
Cleland, J., Conde-Agudelo, A., Peterson, H., Ross, J., & Tsui, A. (2012). Contraception and health. The Lancet, 380(9837), 149–156. https://doi.org/10.1016/S0140-6736(12)60609-6
Cleland, J. G., & Van Ginneken, J. K. (1988). Maternal education and child survival in developing countries: The search for pathways of influence. Social Science & Medicine, 27(12), 1357–1368. https://doi.org/10.1016/0277-9536(88)90201-8
Conde-Agudelo, A. (2000). Maternal morbidity and mortality associated with interpregnancy interval: Cross sectional study. BMJ, 321(7271), 1255–1259. https://doi.org/10.1136/bmj.321.7271.1255
Conde-Agudelo, A., Rosas-Bermúdez, A., & Kafury-Goeta, A. C. (2006). Birth spacing and risk of adverse perinatal outcomes: A meta-analysis. JAMA, 295(15), 1809. https://doi.org/10.1001/jama.295.15.1809
Costa, J. C., Weber, A. M., Darmstadt, G. L., Abdalla, S., & Victora, C. G. (2020). Religious affiliation and immunization coverage in 15 countries in Sub-Saharan Africa. Vaccine, 38(5), 1160–1169. https://doi.org/10.1016/j.vaccine.2019.11.024
Coulibaly, A., Baguiya, A., Meda, I. B., Millogo, T., Koumbem, A. M. A., Garanet, F., & Kouanda, S. (2024). Prevalence and factors associated with short birth interval in the semi-rural community of Kaya, Burkina Faso: Results of a community-based survey. Archives of Public Health, 82(1). https://doi.org/10.1186/s13690-024-01398-y
DaVanzo, J., Hale, L., Razzaque, A., & Rahman, M. (2007). Effects of interpregnancy interval and outcome of the preceding pregnancy on pregnancy outcomes in Matlab, Bangladesh. BJOG: An International Journal of Obstetrics & Gynaecology, 114(9), 1079–1087. https://doi.org/10.1111/j.1471-0528.2007.01338.x
Ettarh, R. R., & Kimani, J. (2012). Determinants of under-five mortality in rural and urban Kenya. Rural and Remote Health, 12(1), 3–11. https://doi.org/10.22605/RRH1812
Finlay, J. E., Özaltin, E., & Canning, D. (2011). The association of maternal age with infant mortality, child anthropometric failure, diarrhoea and anaemia for first births: Evidence from 55 low-and middle-income countries. BMJ Open, 1(2), e000226. Accessed June 16, 2026. https://bmjopen.bmj.com/ content/1/2/e000226.short
Fofana, A. (2017). Déterminants de la mortalité néonatale au Burkina Faso [Determinants of neonatal mortality in Burkina Faso]. Master’s thesis, Université Saint Thomas d’Aquin. Accessed June 16, 2026. https://www.ifris-bf. org/wp-content/uploads/2018/12/20-FOFANA_- D%C3%A9terminant s - d e - la-mor tal it%C3%A9- n%C3%A9onatale-au-Burkina.pdf
Fotso, J. C., Cleland, J., Mberu, B., Mutua, M., & Elungata, P. (2013). Birth spacing and child mortality: An analysis of prospective data from the Nairobi urban health and demographic surveillance system. Journal of Biosocial Science, 45(6), 779–798. https://doi.org/10.1017/S0021932012000570
Hamadou Daouda, Y. (2012). Déterminants de la mortalité infantile et infanto-juvénile et la pauvreté au Niger [Determinants of Infant and Child Mortality and Poverty in Niger]. Revue d’Économie Théorique et Appliquée, 2(1), 23–47. https://doi.org/10.62519/reta.v2n1a2
Institut National de la Statistique et de la Démographie. (1994). Burkina Faso: Enquête démographique et de santé 1993 [Demographic and Health Survey]. Accessed June 16, 2026. https://www.dhsprogram.com/pubs/pdf/FR53/FR53. pdf
Institut National de la Statistique et de la Démographie, & ICF. (2023). Enquête démographique et de santé du Burkina Faso 2021 [Demographic and Health Survey]. Accessed June 16, 2026. https://www.insd.bf/sites/default/files/2023-09/ EDS%20Burkina%20Faso%202021_VF_07-09-23.pdf
Institut National de la Statistique et de la Démographie, & Macro International Inc. (2000). Burkina Faso: Enquête démographique et de santé, 1998-1999 [Demographic and Health Survey]. Accessed June 16, 2026. https://microdata. worldbank.org/index.php/catalog/1332/
Institut National de la Statistique et de la Démographie, & ORC Macro. (2004). Burkina Faso: Enquête démographique et de santé 2003 [Demographic and Health Survey]. Accessed June 16, 2026. https://demostaf.web.ined.fr/index.php/ catalog/103
Karlsson, O. (2019). Religion and child health in West and Central Africa. Population and Development Review, 45(4), 707–738.
https://doi.org/10.1111/padr.12296Ministère de la santé. (2011). Plan National de Développement Sanitaire (PNDS) 2011-2020 [National Health Development Plan 2011-2020].
Ministère de la santé. (2018). Compte rendu de la quatrième rencontre bilan national de mise en oeuvre des mesures de gratuité des soins [Report of the fourth national review meeting on the implementation of free healthcare measures]. Accessed June 16, 2026. https://p4h.world/app/uploads/2023/02/Rapport_4C3A8me20rencontre20bilan20gratuitC3A9_ VF.x23411.pdf
Mosley, W. H., & Chen, L. C. (1984). An analytical framework for the study of child survival in developing countries. Population and Development Review, 10(Suppl), 25–45. https://doi.org/10.2307/2807954
Organisation des Nations Unies. (2015). Transformer notre monde: Le Programme de développement durable à l’horizon 2030. Accessed June 16, 2026. https://unctad.org/system/ files/official-document/ares70d1_fr.pdf
Pullum, T. W. (2008). An assessment of the quality of data on health and nutrition in the DHS surveys, 1993-2003 (DHS Methodological Reports No. 6). Accessed June 16, 2026. https://dhsprogram.com/publications/publication-mr6- methodological-reports.cfm
Rutstein, S. O. (2005). Effects of preceding birth intervals on neonatal, infant and under-five years mortality and nutritional status in developing countries: Evidence from the demographic and health surveys. International Journal of Gynecology & Obstetrics, 89(S1). https://doi.org/10.1016/j.ijgo.2004.11.012
Smith, G. C., Pell, J. P., & Dobbie, R. (2003). Interpregnancy interval and risk of preterm birth and neonatal death: Retrospective cohort study. BMJ, 327(7410), 313. https://doi.org/10.1136/bmj.327.7410.313
United Nations Children’s Fund. (2019). The state of the world’s children 2019: Children, food and nutrition. Accessed June 16, 2026. https://www.UNICEF.org/reports/state-of-worlds-children-2019
United Nations Inter-agency Group for Child Mortality Estimation (UN IGME). (2026). Levels and trends in child mortality: Report 2025. United Nations Children’s Fund (UNICEF). Accessed June 16, 2026. https://data.UNICEF. org/resources/levels-and-trends-in-child-mortality-2025/World Health Organization. (2007). Report of a WHO technical consultation on birth spacing: Geneva, Switzerland, 13–15 June 2005. World Health Organization. Accessed June 16, 2026. https://iris.who.int/server/api/core/bitstreams/58173bae- 0761-4d56-aebf-1e959f88da1d/content
World Health Organization. (2023). World health statistics 2023: Monitoring health for the SDGs, sustainable development goals. Accessed June 16, 2026. https://www.who.int/ publications/i/item/9789240074323