Dominican Republic’s child survival gains leave rural poor and less-educated mothers behind

Under-five deaths have fallen sharply, but poverty, rural residence, limited maternal education and weak access to care continue to shape which children survive.

A new analysis of child survival in the Dominican Republic suggests that progress in lowering deaths among children under five has been real, but uneven. The study, published in the Journal of Global Health, found that the country’s under-five mortality rate fell to 27.8 deaths per 1,000 live births in the dataset it analysed, yet deep social and geographic gaps remained. UNICEF data show the broader national trend: the Dominican Republic has reduced under-five mortality from 59.3 per 1,000 live births in 1990 to 30.6 in 2024, while the World Health Organization reported a rate of 32.3 in 2022.

The paper argues that those gains have slowed as inequality has persisted. Children born to mothers with no schooling had the highest mortality rate in the study, and mortality was also far higher among children in the poorest households than among those in the richest. Rural children faced a heavier burden than urban children, and the pattern extended to basic living conditions: lack of safe water and sanitation was linked to a higher risk of death before age five.

Using multilevel logistic regression, the researchers found that maternal education remained one of the strongest predictors of child survival even after controlling for household and community factors. Poverty, short birth intervals, child stunting, fewer than four antenatal care visits, and younger maternal age were also associated with higher odds of under-five death. At the community level, rural residence, higher regional poverty and weaker health-care access all remained significant. The study also found meaningful clustering by community, indicating that where a child lives still matters even after individual household characteristics are taken into account.

The findings fit with wider evidence that child survival gains are often driven by structural advantages rather than by health care alone. UNICEF’s global data show that under-five mortality has fallen sharply worldwide since 1990, but the Dominican Republic still trails the average for Latin America and the Caribbean, where the study says mortality stood at 14.7 per 1,000 live births in 2022. The authors say this gap reflects the limits of broad progress when poorer households, rural communities and mothers with less education are left behind.

Their policy recommendations centre on familiar but unfinished priorities: keeping girls in school, expanding water and sanitation services in rural areas, widening access to antenatal care and strengthening support for the poorest families. The study also points to the need for more targeted action in high-burden regions, where lower health-care access and greater poverty appear to reinforce one another. While the Dominican Republic has made substantial gains, the research suggests that further reductions in child deaths will depend on closing these persistent social gaps rather than relying on health improvements alone.