Background Childhood mortality from unintentional injuries is disproportionately high in low-and-middle-income-countries (LMICs). Inadequate supervision is often described as contributory to these childhood unintentional injury deaths.

Objective This paper highlights the relationship between caregiver supervision and unintentional injury mortality among children under five in rural Bangladesh.

Method A nested, matched, case-control study was conducted within a large-scale drowning prevention cohort study in Bangladesh. From the baseline survey conducted as part of the study in 2013, 126 cases (under-five children that died from unintentional injuries) and 378 controls (alive, but similarly aged children) were selected at a case-control ratio of 1:3, and individually matched on neighborhood factors. The association between adult caregiver supervision and fatal injuries among under-five children was determined in a multivariable conditional logistic regression analysis, and reported as adjusted matched odds ratio (MOR) with 95% confidence intervals (CIs).

Results Overall, 18.4% of the children aged 0–5 years had some form of supervision by an adult caregiver during the peak period for childhood injury events in Bangladesh, 9 am – 1 pm. Less than 5% of the caregivers had an education above secondary level and 28.6% were involved in agriculture or farming. Under-five children who died from unintentional injury deaths, mostly drowning, had three times higher odds of being unsupervised as compared to alive children (MOR=3.3, 95% CI: 1.6–7.0), while adjusting for child’s gender, age, socioeconomic index, and adult caregiver’s age, education, occupation, and marital status.

Conclusion Appropriate adult supervision is essential for prevention of childhood unintentional injuries in Bangladesh and other similar LMICs. Multi-sectoral efforts to facilitate the design and implementation childhood supervision strategies e.g. community-based daycare are needed.