Analysis of under-five mortality rate and healthcare utilization equity in Hunan Province, China, 2020–2024

Objective To analyze under-five mortality trends, causes of death, and urban–rural/gender disparities in Hunan Province, China (2020–2024) and to evaluate healthcare equity. Methods Under-five death data ( n = 8875) from the provincial reporting system were linked to live-birth records. Mortality rates for early neonates, neonates, infants, and children under five were calculated. Descriptive analysis and chi- square tests were used. Results The under-five mortality rate (U5MR) declined significantly from 4.92‰ in 2020 to 3.29‰ in 2024 ( P < 0.05 for trend). Mortality was significantly higher in rural than urban areas across all age groups: U5MR was 5.88‰ vs. 1.86‰ (rural ≈ 3.2 times higher, P < 0.01); infant mortality was 3.42‰ vs. 1.21‰ ( P < 0.01). Boys had higher mortality than girls (under-five: 4.53‰ vs. 3.68‰, P < 0.01). Preterm birth/birth asphyxia dominated early deaths; accidental asphyxia and drowning prevailed in later childhood, especially in rural areas. The proportion of untreated deaths increased with age and was higher in rural areas ( P < 0.01), primarily due to delayed care or being found dead, whereas treatment withdrawal was more common in urban settings. Conclusion Despite overall progress, significant urban–rural disparities persist. Targeted interventions and strengthened rural emergency care are needed.