Infant and Child Mortality and Its Risk Factors in Sub-Saharan Africa: The Contribution of Healthcare Delivery

Background. Infant and child mortality remains a key indicator of population health in sub-Saharan Africa (SSA), where the risk of death before age five is more than six times higher than in Europe. Biological, maternal, socio-economic and environmental factors interact with the organisation of healthcare delivery, whose impact on under-five mortality has not yet been comprehensively synthesised. This scoping review aimed to map the risk factors for under-five mortality documented in SSA between 2003 and 2023, with particular attention to components of healthcare delivery. Methods. A scoping review was conducted following the Arksey & O’Malley framework as updated by Levac et al., and aligned with the PRISMA-ScR guidelines and the JBI manual. The research question followed the PCC format, targeting infants (0 -11 months) and children under five. Four sources were searched (PubMed/MEDLINE, Web of Science, African Index Medicus, Google Scholar), complemented by grey literature. Double-blind screening (Rayyan) and standardised extraction were conducted by two independent reviewers. A structured narrative synthesis was performed. Results. Twenty-nine documents were retained (19 original studies and 10 contextual documents) covering Western, Eastern, Southern and Central Africa. Four groups of determinants emerged: (i) biological and perinatal factors (malaria, acute respiratory infections, diarrhoea, prematurity, perinatal asphyxia, sickle-cell disease, breastfeeding); (ii) maternal and obstetric factors (maternal education, parity, antenatal care, three-delays model); (iii) socio-economic and environmental determinants (poverty, rural residence, WASH); (iv) healthcare delivery (geographical and financial access, quality of care, continuum of care). User-fee exemption policies and Universal Health Coverage have increased service use but may widen pro-rich inequalities in the absence of targeted measures and parallel quality improvements. Conclusion. Infant and child mortality in SSA is multifactorial and socially structured. In Senegal, the effectiveness of free-care policies depends on improving quality of care, addressing socio-environmental determinants, and pursuing an explicit territorial and social equity strategy. Rigorous impact evaluations are needed to inform future reforms.