ArticlesGlobal, 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
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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