Level and Trends of Zero-Dose Prevalence Among Children in Mozambique: A Repeated Cross-Sectional Analysis of Three Household Surveys, 2011–2023

Background: Despite the proven role of childhood immunization in reducing child mortality, global coverage targets remain unmet. Zero-dose (ZD) children—those who have not received any DTP vaccine dose—represent a critical challenge. Mozambique is among the lowest-coverage countries, with full immunization declining from 66% in 2015 to 38% in 2022–2023. This study determines 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 ZD prevalence trends across provinces and 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 from 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), maternal illiteracy (PR: 0.75; 95% CI: 0.61–0.92), and non-institutional delivery (PR: 0.20; 95% CI: 0.13–0.30). The wealth gap in ZD prevalence widened from 11.3 to 26.3 percentage points, and the urban–rural gap from 3.9 to 15.3 points. Children of mothers with no education had a 22.8% ZD prevalence versus 5.4% among those with secondary or higher education. Conclusion: Rising ZD prevalence and widening inequalities underscore the urgent need for targeted, equity-focused interventions. Strengthening health systems to address these inequities and improve routine immunization services is essential for better child health outcomes in Mozambique.