Reducing World Children Under 5 Mortality: Mixed Progress With Many Regions Not On Track To Meet Millennium Development Goal 4

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Main Category: Pediatrics / Children's Health
Also Included In: Public Health
Article Date: 14 Sep 2009 - 0:00 PDT

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Figures on the progress in reducing world under-5 mortality are released by UNICEF and reported in a comment published Online First and in a recent edition of The Lancet. Generating accurate estimates of under-5 mortality poses a significant challenge because of the limited data available for many developing countries.

In response, experts at UNICEF, WHO, the World Bank, the UN Population Division (UNPD), and members of the academic community formed the Inter-agency Group for Child Mortality Estimation (IGME). The information, based on the work of IGME, indicates that the overall average annual rate of reduction (AARR) is much higher from 2000 to 2008 than it was in 1990 to 2000. Still, the rate of decline is unsatisfactory for the world in general to achieve Millennium Development Goal 4 (MDG4: aims to reduce mortality in children under 5 years by two thirds between 1990 and 2015). However, the authors draw attention to the fact that the effect of interventions such as various vaccination programs and insecticide-treated bed nets, may have been implemented too recently to come out in the estimates.

The comment is the work of Dr Danzhen You, UNICEF, New York, USA, and colleagues. The latest data concerning the year 2008 has caused growing concern that many regions and different countries within them, are not heading in the right direction to meet Millennium Development Goal 4.

The main findings are:

• The estimated global mortality for children under 5 in 2008 is 65 per 1,000 live births, versus 90 in 1990.

• Approximately 8.8 million children under 5 died during 2008, compared with 12.5 million in 1990.

• In 2008, about 10,000 fewer children died compared to 1990 which is the baseline year for the MDGs.

• Africa (51 percent) and Asia (42 percent) collectively represented 93 percent of all deaths globally.

• In measuring progress towards MDG4, the best performing region is Latin America and the Caribbean. It has reduced under-5 mortality by 56 percent between 1990 and 2008, and is on-track to meet MDG4. The region including central and eastern Europe (CEE) and the Commonwealth of Independent States (CIS: formerly USSR) is also on the right track, with a 55 percent reduction from 1990 to 2008.

• The only other two regions on track to meet MDG4 are industrialized (high-income) countries with a 40 percent reduction from 1990 to 2008 and East Asia and Pacific with 48 percent reduction from1990 to 2008.

• Africa continues to be the region with the highest under-5 mortality rates: 132 deaths per 1,000 live births across the whole continent. In sub-Saharan Africa, the rate is 144 deaths per 1,000 live births. This is 24 times the rate in industrialized countries.

• Africa has reduced its under-5 mortality rate by 21 percent in 1990-2008. But, this is not enough to reach MDG4. Asia has had better improvements by reducing its own rate by 38 percent. But, this is still insufficient to reach MDG4. To meet MDG4, the required reduction is two thirds during 1990-2015. This translates to an AARR of 4.4 percent. But to be 'on track' is somewhat different: all countries with mortality lower than 40 per 1,000 live births are considered on track. Countries with mortality rates of 40 or higher are on-track if their AARR is equal to or greater than 4.0 percent. The reason the threshold is set at 4.0 percent rather 4.4 percent is to allow for the margins of uncertainty around the estimates.

• Also, the highest numbers of deaths occurred in sub-Saharan Africa, with 4.4 million children under-5 dying during 2008. This represents half of the total world deaths. Due to high fertility in this region, combined with high mortality, numbers of deaths have in fact increased from 4.0 million in 1990 to 4.4 million in 2008.

• In general, 99 percent of deaths occurred in developing countries, with 1 percent in high-income countries.

• The mortality in developing countries was 71 deaths per 1,000. This was 12 times that in industrialized countries (6 per 1,000).

• In sub-Saharan Africa one in seven children dies before their fifth birthday. In a sub-region of this region, such as West and Central Africa, this figure was even higher, at one in six children.

• Under-5 mortality is increasingly concentrated: 75 percent of the world's under-5 deaths in 2008 occurred in only eighteen countries. Half of the deaths occurred in only five countries: India, Nigeria, Democratic Republic of the Congo, Pakistan, and China. And India and Nigeria together account for nearly one-third of the total number of under-5 deaths worldwide (21 percent and 12 percent, correspondingly).

• At country level and based on the average annual rate of reduction among countries with under-5 mortality of 40 or higher, the best performers include: Nepal, Bangladesh, Eritrea, Lao, Mongolia, Bolivia, and Malawi which have all consistently achieved annual rates of reduction of under-5 mortality of 4.5 percent or higher. Additionally, Niger, Malawi, Mozambique, and Ethiopia have reached complete reductions of more than a 100 per 1,000 live births since 1990.These countries are a testimony that the MDG4 concept is attainable, even in the poorest environments.

• In general, the recent survey data integrated in these estimates reflect mortality over the previous 3 to 5 years. As a result the most important improvements in coverage in recent years, such as insecticide-treated bed nets for malaria, prevention of mother-to-child transmission and paediatric HIV, HiB vaccine, and additional progress on measles, tetanus, and vitamin A supplementation, might not yet entirely be reflected in these mortality data.

• The rate of decline in under-5 mortality is still inadequate to attain the goal by 2015. This is the case particularly in sub-Saharan Africa and South Asia. It is shocking to observe that among the 67 countries with high mortality rates of 40 per 1,000 or more, only ten countries are on track to meet MDG4.

• Apart from the countries with highest mortality rates, there is a need for a renewed focus on high-burden countries with the greatest numbers of deaths, such as India, Nigeria, Democratic Republic of the Congo, Pakistan, and China (which make up nearly 50 percent of all under-5 deaths).

• A breakdown of the countries with the highest mortality levels or the slowest progress shows that those in conflict or transition are over-represented. Better practices must be adopted in these countries. Moreover, donors must prioritize these nations in support programs.

The authors write in conclusion: "Accelerated progress can be achieved, even in the poorest environments, through: integrated, evidence-driven, and community-based programmes that focus on addressing the major causes of death, including pneumonia, diarrhoea, newborn disorders, malaria, HIV, and undernutrition; reaching the unreached with a basic package of interventions at large scale and achieving coverage with equity; and using data for action and advocacy."

"Levels and trends in under-5 mortality, 1990-2008"
Danzhen You, Tessa Wardlaw, Peter Salama, Gareth Jones
DOI: 10.1016/S0140-6736(09)61601-9
The Lancet

Written by Stephanie Brunner (B.A.)
Copyright: Medical News Today
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