Fast track — ArticlesNeonatal, postneonatal, childhood, and under-5 mortality for 187 countries, 1970–2010: a systematic analysis of progress towards Millennium Development Goal 4
Introduction
There are only 5 years left 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. Regular assessment of levels and trends in child mortality is essential for countries to ascertain their progress towards this goal and to take action to meet it. Previous appraisals of mortality in children younger than 5 years suggest that few countries are on track to meet MDG 4.1, 2, 3 In each of these studies,1, 2, 3 no more than 26% of low-income and middle-income countries examined were deemed to be on track to reach this target. Groups such as the Countdown to 2015 Initiative3 have therefore tried to rally support to accelerate progress in child mortality.4, 5, 6, 7
The MDG 4 target has shifted the focus from tracking levels of child mortality to assessing whether countries are reducing child mortality at the 4·4% rate per year needed to achieve the two-thirds reduction in 25 years. Accurate assessments of rates of change need more robust measurement with narrower uncertainty intervals than do assessments of levels. Although there have been substantial investments in the collection of data such as summary and complete birth histories to measure child mortality, assessments of trends have varied substantially from year to year and from source to source. For example, the list of the ten countries with the fastest rates of decline in child mortality between 1990 and 2007, as reported by UNICEF in 2008,8 UNICEF in 2009,9 and the UN Population Division (UNPD) in 2009,10 have only three countries in common: Portugal, Vietnam, and the Maldives. In 2008, UNICEF reported that Thailand had the fastest rate of decline in the world, leading researchers to undertake a case study of this success.11 But in 2009, UNICEF reported that Thailand had only the 47th fastest rate of decline;9 in a UNPD report, the country had the fourth fastest rate of decline.10 Such confusion about the true extent of progress can foster policy inaction in countries, precisely at a time when targeted, effective programmes are needed most. Variation in the assessments of rates of decline indicates the availability and use of different datasets, different analytical methods, and different decisions about data quality by the analysts.
Evidence from several low-income countries suggests that in some countries, declines in mortality in children younger than 5 years might have accelerated since 2000,12, 13, 14 whereas in others, the rate of decline might be slowing. During the 25 years of the MDG 4 target, countries are likely to experience accelerations and decelerations in rates of decline. Acceleration matters because it could be an early indication of policy or programme success. The need to use the best datasets and the most valid methods for assessing child mortality over time is only intensified when trying to detect such accelerations and decelerations. In view of the scale-up in development assistance for health,15 the expansion of insecticide-treated net coverage,16 activity of the GAVI Alliance,17 and rollout of antiretroviral drugs,18 there are many reasons to hope that accelerations might be occurring in some countries.
In this study, we examined levels, rates of decline, and accelerations and decelerations in rates of decline in neonatal, postneonatal, childhood, and under-5 mortality from 1970 to 2010 in 187 countries. This study was aided by four important developments since the previous studies were done. First, we made use of data that have been newly released or acquired during an intensive 3-year effort to obtain access to microdata (individual-level data) and tabulated data sources. Second, we used new methods to analyse data from summary birth histories with reduced bias and measurement error.19 Third, we applied new data synthesis methods with enhanced predictive validity to combine data from several sources and capture both sampling and non-sampling error patterns. This new method requires many fewer subjective inputs to estimation, ensuring that the output is strongly grounded in empirical data and is as reproducible as possible. Finally, we took advantage of more data and better models with improved predictive validity to analyse country patterns of neonatal, postneonatal, and childhood mortality.
Section snippets
Data sources
By use of improved methods, we substantially updated the database of measurements for under-5 mortality (defined as the probability of death between birth and age 5 years) used by Murray and colleagues1 in 2007 to include newly released or obtained data, as well as reanalysed microdata from many of the sources included in the 2007 database. We retained measurements from the original database if we were not able to reanalyse the source data. The database now contains 7933 more measurements than
Results
Table 1 shows our estimates and uncertainty intervals for under-5 mortality in all 187 countries every 10 years from 1970 to 2010. A full time series of results is available for each country in the webappendix (pp 18–204); four examples of these data plots are shown in figure 1. Norway is an example of a country with complete vital registration data. Our GPR model produced estimates that were very close to the observed data with narrow uncertainty intervals, representing sampling uncertainty
Discussion
Our analysis of 16 174 measurements of child mortality in 187 countries shows that the number of deaths in children younger than 5 years dropped from 16 million in 1970 to 7·7 million in 2010. In developing countries, mortality in children younger than 5 years declined by 35% from 1990 to 2010, a yearly rate of 2·1%. This rate of decline is lower than the MDG 4 target of 4·4% per year but represents substantial progress across countries; no countries have a rate of under-5 mortality of more
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