Temporal Validation Changes the Apparent Public-Health Utility of Under-Five Mortality Prediction in Bangladesh: A Four-Round DHS Machine-Learning Study

Abstract

Background: Under-five mortality in Bangladesh remains uneven despite national progress. DHS-based prediction models may guide targeted follow-up, but only if validation reflects future use. We examined how validation design changes apparent prediction performance. Methods: Four BDHS rounds (2011-2022; 33,962 children; 1,290 deaths) were analysed with a 26-feature pipeline and three model classes under four validation regimes, including cross-survey temporal validation (train 2011+2014, calibrate 2017, test 2022). A 32-unit ELU multilayer perceptron was selected via genetic-algorithm neural architecture search. AUROC used 2,000 bootstrap resamples; screening utility used sensitivity, PPV, and number needed to screen (NNS) at fixed capacity. Results: Validation regime altered public-health interpretation more than model class. NAS MLP AUROC ranged from 0.669 (2022-only random) to 0.775 (pooled random), with temporal AUROC 0.730. At the top-10% temporal threshold, NAS identified 152/355 deaths in 2022 (sensitivity 42.8%, PPV 13.2%, NNS 7.6). NNS across designs ranged from 5.6 to 11.0. Conclusions: Validation-regime choice changed screening workload and apparent policy value more than architecture. Temporal validation supports defensible estimates of follow-up and referral demand; DHS child-mortality studies should report sensitivity, PPV, and NNS before programmatic use.