Elsevier

The Lancet

Volume 384, Issue 9947, 13–19 September 2014, Pages 957-979
The Lancet

Articles
Global, regional, and national levels of neonatal, infant, and under-5 mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013

https://doi.org/10.1016/S0140-6736(14)60497-9Get rights and content

Summary

Background

Remarkable financial and political efforts have been focused on the reduction of child mortality during the past few decades. Timely measurements of levels and trends in under-5 mortality are important to assess progress towards the Millennium Development Goal 4 (MDG 4) target of reduction of child mortality by two thirds from 1990 to 2015, and to identify models of success.

Methods

We generated updated estimates of child mortality in early neonatal (age 0–6 days), late neonatal (7–28 days), postneonatal (29–364 days), childhood (1–4 years), and under-5 (0–4 years) age groups for 188 countries from 1970 to 2013, with more than 29 000 survey, census, vital registration, and sample registration datapoints. We used Gaussian process regression with adjustments for bias and non-sampling error to synthesise the data for under-5 mortality for each country, and a separate model to estimate mortality for more detailed age groups. We used explanatory mixed effects regression models to assess the association between under-5 mortality and income per person, maternal education, HIV child death rates, secular shifts, and other factors. To quantify the contribution of these different factors and birth numbers to the change in numbers of deaths in under-5 age groups from 1990 to 2013, we used Shapley decomposition. We used estimated rates of change between 2000 and 2013 to construct under-5 mortality rate scenarios out to 2030.

Findings

We estimated that 6·3 million (95% UI 6·0–6·6) children under-5 died in 2013, a 64% reduction from 17·6 million (17·1–18·1) in 1970. In 2013, child mortality rates ranged from 152·5 per 1000 livebirths (130·6–177·4) in Guinea-Bissau to 2·3 (1·8–2·9) per 1000 in Singapore. The annualised rates of change from 1990 to 2013 ranged from −6·8% to 0·1%. 99 of 188 countries, including 43 of 48 countries in sub-Saharan Africa, had faster decreases in child mortality during 2000–13 than during 1990–2000. In 2013, neonatal deaths accounted for 41·6% of under-5 deaths compared with 37·4% in 1990. Compared with 1990, in 2013, rising numbers of births, especially in sub-Saharan Africa, led to 1·4 million more child deaths, and rising income per person and maternal education led to 0·9 million and 2·2 million fewer deaths, respectively. Changes in secular trends led to 4·2 million fewer deaths. Unexplained factors accounted for only −1% of the change in child deaths. In 30 developing countries, decreases since 2000 have been faster than predicted attributable to income, education, and secular shift alone.

Interpretation

Only 27 developing countries are expected to achieve MDG 4. Decreases since 2000 in under-5 mortality rates are accelerating in many developing countries, especially in sub-Saharan Africa. The Millennium Declaration and increased development assistance for health might have been a factor in faster decreases in some developing countries. Without further accelerated progress, many countries in west and central Africa will still have high levels of under-5 mortality in 2030.

Funding

Bill & Melinda Gates Foundation, US Agency for International Development.

Introduction

During the past few decades, substantial political, donor, and country focus has been placed on the reduction of child mortality. The Millennium Development Goal 4 (MDG 4) target of reduction of child mortality by two thirds from 1990 to 2015 has captured the attention of high-level leaders.1, 2, 3, 4, 5 The UN Commission for Accountability for Women's and Children's Health is a further reminder of intensified interest, along with numerous initiatives from donor organisations.4, 6, 7 Global interest in child mortality reduction is not new; the child survival revolution,8 Jim Grant's pioneering work at UNICEF on child interventions,9 and the Health for All by the Year 2000 campaign10 are examples of the worldwide focus on improvement of child survival that began more than three decades ago. Key actors such as the governments of the USA, Ethiopia, and India, together with UNICEF, are arguing for a continued post-2015 focus on further reductions in child mortality to eliminate all child deaths from preventable causes by 2035.1 This global goal is mainly motivated, not only by the huge disparities between and within nations in child mortality, but also by compelling evidence that child mortality can be reduced even in low-resource settings.11, 12

Child mortality worldwide is decreasing and has been in many countries for many decades.1, 13, 14, 15, 16, 17, 18, 19, 20 The decreases achieved in high-income, middle-income, and low-income countries surely count among the more important achievements for humanity in the past 60 years.21, 22, 23, 24, 25, 26, 27 Four types of interconnected explanations have been suggested for the sustained but heterogeneous decrease in child mortality. Demographers and other social scientists have identified long-term associations between child mortality and maternal education, income per person, and technology change.28, 29, 30, 31, 32 Health-system researchers have explained why some health systems are able to achieve faster rates of decrease or lower levels of child mortality at similar amounts of income and health expenditure than are others.33 More recently, detailed analyses by the Countdown to 2015 and other groups have sought to explain levels and trends in child mortality through the coverage of a short list of proven technologies.5, 34 Political scientists have called attention to the potential role of global collective action, such as the Millennium Declaration itself, as a key contributor to social phenomenon and health development.35, 36 All of these explanations have merit; understanding the balance and interconnection between them might provide important insights for future global and national action to accelerate decreases in child mortality.

Timely, local, and valid assessments of trends in child mortality along with the associated drivers of these trends can provide an important input to national, regional, and global debates on next steps. Although the long-term trend in child mortality has been downward, important heterogeneity exists across countries and age groups. Understanding this heterogeneity can help to catalyse and optimise a process of shared learning from success stories and to identify crucial areas that need more attention.

Here, we aimed to use data from the Global Burden of Diseases, Injuries, and Risk Factors Study 2013 (GBD 2013) to assess levels and trends of child mortality, and to explore key factors associated with progress. We aimed to use the GBD 2013 data to report three interrelated themes: estimate the levels and trends in early neonatal (age 0–6 days), late neonatal (7–28 days), postneonatal (29–364 days), childhood (1–4 years), and under-5 (0–4 years) mortality from 1990 to 2013, for 188 countries (with one additional country comparing to GBD 201037 because we included Sudan and South Sudan in this analysis) with the most up-to-date data and methods; explore the contribution of broad drivers of child mortality during the past few decades and whether accelerated reductions have been beyond what might have been expected after 2000; and forecast child mortality to 2030 to identify populations that are likely to be the main challenges to further global progress with child survival strategies in the mid-term.

Section snippets

Estimation of child, infant, and neonatal mortality by country during 1990–2013

We used the broad data analysis strategy from the Global Burden of Diseases, Injuries, and Risk Factors Study 2010 (GBD 2010) to measure national trends in child mortality. The appendix summarises the methods we used,13, 14, 18 including further refinements on the basis of feedback for GBD 2010. Figure 1 shows the analytical steps we used to estimate under-5 mortality. This process had three components. First, we used improved formal demographic methods to analyse empirical data for child

Results

Figure 2 shows the trend in global under-5 mortality rates and the annualised rate of change in the years from 1970 to 2013. Worldwide, under-5 mortality decreased by slightly more than two-thirds from 143 per 1000 livebirths in 1970, to 85 per 1000 in 1990, and to 44 per 1000 in 2013. The global number of under-5 deaths fell from 17·6 million in 1970, to 12·2 million in 1990, and to 6·3 million in 2013. Child mortality fell at an annual rate of between 2·5% and 3·0% from 1970 until 1985, but

Discussion

The dominant global health focus on improvement of child survival in the past four decades has been extremely successful, although more remains to be done. Child mortality levels decreased, on average, by 2·6% per year from 1970 to 1985, then slowed down for a decade until 1997, began to accelerate, and since 2005, have fallen by an average of 3·6% per year. Accelerated decreases have been recorded in India, nearly all countries in sub-Saharan Africa, and eastern Europe. Conversely, the rate of

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