New estimates from the Institute for Health Metrics and Evaluation (IHME), University of Washington, Seattle, USA, show that global deaths in children under-5 years are more than 800,000 lower than the latest estimate provided by UNICEF in 2008. The data also show that many poorer countries are showing accelerated progress. Among high-income countries, where less than 1% of total global under-5 deaths occur, the UK and USA are lagging behind other nations. The findings are reported in an Article published Online First and in an upcoming Lancet, written by Dr Christopher Murray of IHME and colleagues.
Previous assessments have highlighted that less than a quarter of countries are on track to achieve Millennium Development Goal 4 (MDG 4), which calls for a two-thirds reduction in mortality in children younger than 5 years between 1990 and 2015. In view of policy initiatives and investments made since 2000, it is important to see if there is acceleration towards the MDG 4 target. In this new work, the authors assessed levels and trends in child mortality for 187 countries from 1970 to 2010. They used data from all available sources, including vital registration systems, summary birth histories in censuses and surveys, and complete birth histories. This is the first study to use a technique called Gaussian process regression (GPR) to estimate child mortality—which is better at providing estimates where there is limited or no data.
The data show that worldwide mortality in children younger than 5 years has dropped from 11•9 million deaths in 1990 to an estimated 7•7 million deaths in 2010, consisting of 3•1 million neonatal deaths (0—27 days), 2•3 million postneonatal deaths (28 days—1 year), and 2•3 million childhood deaths (aged 1 years). A third of deaths in children younger than 5 years occur in south Asia and half occur in sub-Saharan Africa. Globally, child mortality rates are declining by around 60% in the period 1970-2010, with neonatal mortality dropping by 57%, postneonatal mortality by 62%, and childhood mortality by 60%, and each has declined globally by just over 2% per year in that period.
The authors say their assessment yields substantially lower estimates of child mortality than did previous studies. For example, UNICEF reported 8•77 million deaths in 2008, while the new study estimated 7•95 million for the same year—a difference of 820,000. They say the lower estimate is largely driven by newer surveys that show that declines in child mortality have been faster than projected and by the improved predictive validity of GPR compared with other methods, adding: "The change in the overall numbers and the even more striking change in the estimated rates of decline from 1990 to 2008 due to new data and improved methods highlight why it is important to continually update and refine the measurement of child mortality."
Overall progress is promising. In 1970 there were 40 countries with mortality higher than 200 per 1000 live births (200/1000); in 1990 this had fallen to 12 countries and by 2010 there were no countries with rates this high. In 13 regions of the world, including all regions in sub-Saharan Africa, there is evidence of accelerating declines from 2000 to 2010 compared with 1990 to 2000. Within sub-Saharan Africa, rates of decline have increased by more than 1% in Angola, Botswana, Cameroon, Congo, Democratic Republic of the Congo, Kenya, Lesotho, Liberia, Rwanda, Senegal, Sierra Leone, Swaziland, and The Gambia. Despite this, the new data show that only 31 developing countries, and 54 countries in total, are on track to meet MDG4.
While high-income countries have much lower child mortality than other regions, there are stark differences between countries. As with other recent mortality studies, the UK is performing badly and has the highest child mortality in Western Europe, at 5.3/1000 (followed by Malta and Andorra). Globally, the UK fell from 12th best in 1970 to 33rd best in 2010. Despite this, the UK has reduced its mortality by three quarters since 1970 and almost half since 1990. 12 of the other 21 countries in Western Europe had higher child mortality than the UK in 1970 (Austria, Belgium, Cyprus, Germany, Greece, Ireland, Israel, Italy, Luxembourg, Malta, Portugal and Spain). All have since overtaken the UK. Portugal has made massive progress since 1970, from 74/1000 down to 3.3/1000 in 2010. Iceland has the lowest child mortality estimate in 2010 at 2.6/1000, followed by Sweden (2.7) and Cyprus (2.8).
The USA ranks 42nd in the world in child mortality (from lowest to highest), with an estimated 6.7/1000 in 2010. Rates of decline between 1990-2010 in both the USA and Canada are at 2—3% per year, while most other high-income countries have annual rates of decline of 3—5%.
Of all 38 countries in the world with under-5 mortality higher than 80/1000 in 2010, 34 are in sub-Saharan Africa. Countries in southern Africa have notably lower under-5 mortality rates than do countries in other sub-Saharan regions; the west sub-Saharan African countries of Nigeria, Guinea-Bissau, Niger, Mali and Chad have the highest rates of under-5 mortality in the world.
Across all developing countries in 1990—2010, the yearly rate of decline in under-5 mortality is 2•1%, a 35% decline overall. This is not enough to meet MDG4, which requires an annual rate of decline of 4.4% 1990—2015. However bursts of rapid decline are possible. For example, 66 countries have decreased child mortality by more than 30% in just 5 years during the period of this study, for example Italy, Japan, Liberia, Poland, and Portugal.
The fastest rates of decline occurred in many Latin American and north African countries. Some countries in sub-Saharan Africa have had yearly rates of decline of more than 3%—Comoros, Eritrea, Ethiopia, Liberia, Madagascar, Malawi, and Niger. The authors say immunisation, insecticide-treated bednets for malaria prevention, treatment to prevent mother-child HIV transmission, and antiretroviral drugs could all be aiding this accelerated decline. They say follow-up of this new study with country case-studies will be crucial, and ask: "Can we link the accelerated declines in mortality to the delivery of known, effective interventions? Are there policy lessons on how governments and other organisations have tackled particular child health problems?"
The authors conclude: "Rapidly reducing child deaths must remain a global health priority. This reduction will be aided by regular, careful, and rigorous assessments with new and comparable methods that inspire confidence in the level, and more importantly, the rate of decline of child mortality worldwide."
See links below to spreadsheets for country rankings in 1970, 1990 and 2010 plus a list of the 54 countries on track to meet MDG4
http://press.thelancet.com/mdg4countries.xls
http://press.thelancet.com/leaguetables.xls
For Dr Christopher Murray, please contact either William Heisel or Jill Oviatt, IHME Communications. William Heisel T) +1 (206) 897-2886 / + 1 (206) 612-0739 E) wheisel@uw.edu
Jill Oviatt T) +1 (206) 897-2862 /+1 (206) 861-6684 E) oviattj@uw.edu
For full Article, see: http://press.thelancet.com/murraychild.pdf
*Note to editors: No accompanying Comment is available at this time, but one will be ready for when the paper appears in a future issue of The Lancet
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