Level and trends of zero-dose prevalence children in Mozambique: a repeated cross-sectional analysis of three household surveys, 2011-2023

Background: Despite the proven role of childhood immunization in reducing mortality, global coverage targets remain unmet. Zero-dose (ZD) children—those who have not received any dose of the DTP vaccine—remain a critical challenge. Mozambique is among the countries with the lowest vaccination coverage, with full immunization declining from 66% in 2015 to 38% in 2022–2023. This study aims to determine the levels and trends of ZD prevalence in Mozambique. Methods: We analyzed data from three nationally representative surveys—DHS 2011, IMASIDA 2015, and DHS 2022/23—focusing on children aged 12–23 and 24–35 months. The analysis examined trends in ZD prevalence across provinces and explored disparities by urban-rural residence, wealth index, and maternal education. Adjusted prevalence ratios (PRs) and 95% confidence intervals (CIs) were estimated using log-binomial regression. Results: ZD prevalence increased from 5.4% to 14.3% (2015–2022) among children aged 12–23 months and 6.4% to 16.0% among those aged 24–35 months. Key risk factors included rural residence (PR: 0.50; 95% CI: 0.29–0.88 for urban compared to rural), maternal illiteracy (PR: 0.75; 95% CI: 0.61–0.92 for primary education vs. illiteracy), and non-institutional delivery (PR: 0.20; 95% CI: 0.13–0.30 for institutional delivery vs. home birth). The gap in ZD prevalence between the poorest and wealthiest households grew from 11.3 to 26.3 percentage points, and the urban- rural gap grew from 3.9 to 15.3 points. In 2022, children of mothers with no education had a 22.8% ZD prevalence versus 5.4% among those with secondary or higher education. Conclusion: The rising ZD prevalence and widening inequalities underscore the urgent need for targeted, equity-focused interventions. Strengthening health systems to reduce these inequities and improve routine immunization services is essential for improving child health outcomes in Mozambique.