Direct and Indirect Effects of Adolescent Motherhood on Under-Five Mortality in Pakistan: Evidence From a Nationally Representative Survey.

BACKGROUND: Adolescent motherhood is associated with adverse child survival outcomes, particularly in low- and middle-income settings. Maternal and child health (MCH) service utilization may represent an important pathway linking adolescent motherhood with child survival, but evidence from Pakistan remains limited. This study examined the association between adolescent motherhood and under-five mortality and assessed the statistical indirect association through MCH service utilization. METHODS: We analyzed nationally representative data from the 2018 Pakistan Demographic and Health Survey, including 8159 mother-child observations. Under-five mortality was examined as a time-to-event outcome. We used multivariable generalized structural equation modeling with a Weibull proportional hazards specification to estimate associations between adolescent motherhood, MCH service utilization, and under-five mortality. We constructed the MCH service utilization index from indicators of antenatal care, skilled delivery care, and postnatal care. Indirect associations were evaluated using 5000 bootstrap replications and 95% bias-corrected bootstrap confidence intervals. All analyses were conducted using STATA version 17.1. RESULTS: Overall, 4.09% of children died before age five, and 37.55% were born to adolescent mothers. After adjustment for prespecified covariates, adolescent motherhood was associated with higher under-five mortality (HR = 2.05, p < 0.001) and lower MCH service utilization (β = -0.02, p = 0.044). Higher MCH service utilization was associated with lower under-five mortality (HR = 0.26, p < 0.001). After accounting for MCH service utilization, adolescent motherhood remained associated with higher under-five mortality (HR = 1.99, p < 0.001). The indirect association through MCH service utilization was positive and statistically supported (β = 0.0223; bootstrap SE = 0.0103; 95% [BCCI: 0.0038-0.0398]). CONCLUSION: Adolescent motherhood was associated with higher under-five mortality and lower MCH service utilization, while greater MCH service utilization was associated with lower under-five mortality. The findings suggest that differences in MCH service utilization account for part of the observed association between adolescent motherhood and under-five mortality. Improving access to and utilization of MCH services, alongside interventions addressing adolescent pregnancy and broader social determinants of child health, may contribute to improved child survival in Pakistan.