Global, regional, and national causes of under-5 mortality in 2000–15: an updated systematic analysis with implications for the Sustainable Development Goals

Abstract

SummaryBackgroundDespite remarkable progress in the improvement of child survival between 1990 and 2015, the Millennium Development Goal (MDG) 4 target of a two-thirds reduction of under-5 mortality rate (U5MR) was not achieved globally. In this paper, we updated our annual estimates of child mortality by cause to 2000–15 to reflect on progress toward the MDG 4 and consider implications for the Sustainable Development Goals (SDG) target for child survival.MethodsWe increased the estimation input data for causes of deaths by 43% among neonates and 23% among 1–59-month-olds, respectively. We used adequate vital registration (VR) data where available, and modelled cause-specific mortality fractions applying multinomial logistic regressions using adequate VR for low U5MR countries and verbal autopsy data for high U5MR countries. We updated the estimation to use Plasmodium falciparum parasite rate in place of malaria index in the modelling of malaria deaths; to use adjusted empirical estimates instead of modelled estimates for China; and to consider the effects of pneumococcal conjugate vaccine and rotavirus vaccine in the estimation.FindingsIn 2015, among the 5·9 million under-5 deaths, 2·7 million occurred in the neonatal period. The leading under-5 causes were preterm birth complications (1·055 million [95% uncertainty range (UR) 0·935–1·179]), pneumonia (0·921 million [0·812 −1·117]), and intrapartum-related events (0·691 million [0·598 −0·778]). In the two MDG regions with the most under-5 deaths, the leading cause was pneumonia in sub-Saharan Africa and preterm birth complications in southern Asia. Reductions in mortality rates for pneumonia, diarrhoea, neonatal intrapartum-related events, malaria, and measles were responsible for 61% of the total reduction of 35 per 1000 livebirths in U5MR in 2000–15. Stratified by U5MR, pneumonia was the leading cause in countries with very high U5MR. Preterm birth complications and pneumonia were both important in high, medium high, and medium child mortality countries; whereas congenital abnormalities was the most important cause in countries with low and very low U5MR.InterpretationIn the SDG era, countries are advised to prioritise child survival policy and programmes based on their child cause-of-death composition. Continued and enhanced efforts to scale up proven life-saving interventions are needed to achieve the SDG child survival target.FundingBill & Melinda Gates Foundation, WHO.

Cause-specific child mortality performance and contributions to all-cause child mortality, and number of child lives saved during the Millennium Development Goals era: a country-level analysis

“…The distribution of causes of child mortality has been updated, including the progress toward the MDG 4 target, at global, regional, and national levels [1–10]. …”

“…Recently global communities have become increasingly interested in investigating cause-specific progress (i.e. the annual change in mortality reduction) [1,4]; however, such analyses have been restricted to the global or regional level, and have not been conducted at the country level. Furthermore, some studies [1,2] have investigated cause-specific annual changes by U5MR strata (cutoffs: very high mortality stratum, 100 per 1000 live births; high, 75; medium-high, 50; medium, 25; low, 10; very low, less than 10).…”

“…the annual change in mortality reduction) [1,4]; however, such analyses have been restricted to the global or regional level, and have not been conducted at the country level. Furthermore, some studies [1,2] have investigated cause-specific annual changes by U5MR strata (cutoffs: very high mortality stratum, 100 per 1000 live births; high, 75; medium-high, 50; medium, 25; low, 10; very low, less than 10). Prior studies [1,4,7] examining the leading causes and their overall progress at the global level, in specific regions, or across mortality strata might not have revealed features of nation-specific progress if national progress was not homogenous within the group.…”

“…Furthermore, some studies [1,2] have investigated cause-specific annual changes by U5MR strata (cutoffs: very high mortality stratum, 100 per 1000 live births; high, 75; medium-high, 50; medium, 25; low, 10; very low, less than 10). Prior studies [1,4,7] examining the leading causes and their overall progress at the global level, in specific regions, or across mortality strata might not have revealed features of nation-specific progress if national progress was not homogenous within the group. Furthermore, the results at the global level, in specific regions, or across mortality strata might have been disproportionally affected by a small number of countries with the greatest burden of child deaths, such as India, Ethiopia, Pakistan, and Nigeria.…”

“…Furthermore, the results at the global level, in specific regions, or across mortality strata might have been disproportionally affected by a small number of countries with the greatest burden of child deaths, such as India, Ethiopia, Pakistan, and Nigeria. There has been substantial variation in investments in U5MR reduction in 2000–2015 by disease [1]. Understanding the impact of these investments on cause-specific mortality is required at the country level, considering the implications for national priorities.…”