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Multicenter Study
. 2014 Sep 13;384(9947):957-79.
doi: 10.1016/S0140-6736(14)60497-9. Epub 2014 May 2.

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

Haidong Wang  1 , Chelsea A Liddell  2 , Matthew M Coates  2 , Meghan D Mooney  2 , Carly E Levitz  2 , Austin E Schumacher  2 , Henry Apfel  2 , Marissa Iannarone  2 , Bryan Phillips  2 , Katherine T Lofgren  2 , Logan Sandar  2 , Rob E Dorrington  3 , Ivo Rakovac  4 , Troy A Jacobs  5 , Xiaofeng Liang  6 , Maigeng Zhou  6 , Jun Zhu  7 , Gonghuan Yang  8 , Yanping Wang  7 , Shiwei Liu  6 , Yichong Li  6 , Ayse Abbasoglu Ozgoren  9 , Semaw Ferede Abera  10 , Ibrahim Abubakar  11 , Tom Achoki  12 , Ademola Adelekan  13 , Zanfina Ademi  14 , Zewdie Aderaw Alemu  15 , Peter J Allen  16 , Mohammad AbdulAziz AlMazroa  17 , Elena Alvarez  18 , Adansi A Amankwaa  19 , Azmeraw T Amare  20 , Walid Ammar  21 , Palwasha Anwari  22 , Solveig Argeseanu Cunningham  23 , Majed Masoud Asad  24 , Reza Assadi  25 , Amitava Banerjee  26 , Sanjay Basu  27 , Neeraj Bedi  28 , Tolesa Bekele  29 , Michelle L Bell  30 , Zulfiqar Bhutta  31 , Jed D Blore  14 , Berrak Bora Basara  32 , Soufiane Boufous  33 , Nicholas Breitborde  34 , Nigel G Bruce  35 , Linh Ngoc Bui  36 , Jonathan R Carapetis  37 , Rosario Cárdenas  38 , David O Carpenter  39 , Valeria Caso  40 , Ruben Estanislao Castro  41 , Ferrán Catalá-Lopéz  42 , Alanur Cavlin  9 , Xuan Che  43 , Peggy Pei-Chia Chiang  44 , Rajiv Chowdhury  45 , Costas A Christophi  46 , Ting-Wu Chuang  47 , Massimo Cirillo  48 , Iuri da Costa Leite  49 , Karen J Courville  50 , Lalit Dandona  51 , Rakhi Dandona  52 , Adrian Davis  53 , Anand Dayama  54 , Kebede Deribe  55 , Samath D Dharmaratne  56 , Mukesh K Dherani  35 , Uğur Dilmen  32 , Eric L Ding  57 , Karen M Edmond  58 , Sergei Petrovich Ermakov  59 , Farshad Farzadfar  60 , Seyed-Mohammad Fereshtehnejad  61 , Daniel Obadare Fijabi  62 , Nataliya Foigt  63 , Mohammad H Forouzanfar  2 , Ana C Garcia  64 , Johanna M Geleijnse  65 , Bradford D Gessner  66 , Ketevan Goginashvili  67 , Philimon Gona  68 , Atsushi Goto  69 , Hebe N Gouda  70 , Mark A Green  71 , Karen Fern Greenwell  72 , Harish Chander Gugnani  73 , Rahul Gupta  74 , Randah Ribhi Hamadeh  75 , Mouhanad Hammami  76 , Hilda L Harb  21 , Simon Hay  77 , Mohammad T Hedayati  78 , H Dean Hosgood  79 , Damian G Hoy  80 , Bulat T Idrisov  81 , Farhad Islami  82 , Samaya Ismayilova  83 , Vivekanand Jha  84 , Guohong Jiang  85 , Jost B Jonas  86 , Knud Juel  87 , Edmond Kato Kabagambe  88 , Dhruv S Kazi  89 , Andre Pascal Kengne  90 , Maia Kereselidze  91 , Yousef Saleh Khader  92 , Shams Eldin Ali Hassan Khalifa  93 , Young-Ho Khang  94 , Daniel Kim  95 , Yohannes Kinfu  96 , Jonas M Kinge  97 , Yoshihiro Kokubo  98 , Soewarta Kosen  99 , Barthelemy Kuate Defo  100 , G Anil Kumar  52 , Kaushalendra Kumar  101 , Ravi B Kumar  52 , Taavi Lai  102 , Qing Lan  103 , Anders Larsson  104 , Jong-Tae Lee  105 , Mall Leinsalu  106 , Stephen S Lim  2 , Steven E Lipshultz  107 , Giancarlo Logroscino  108 , Paulo A Lotufo  109 , Raimundas Lunevicius  110 , Ronan Anthony Lyons  111 , Stefan Ma  112 , Abbas Ali Mahdi  113 , Melvin Barrientos Marzan  114 , Mohammad Taufiq Mashal  115 , Tasara T Mazorodze  116 , John J McGrath  70 , Ziad A Memish  17 , Walter Mendoza  117 , George A Mensah  118 , Atte Meretoja  14 , Ted R Miller  119 , Edward J Mills  120 , Karzan Abdulmuhsin Mohammad  121 , Ali H Mokdad  2 , Lorenzo Monasta  122 , Marcella Montico  122 , Ami R Moore  123 , Joanna Moschandreas  124 , William T Msemburi  90 , Ulrich O Mueller  125 , Magdalena M Muszynska  126 , Mohsen Naghavi  2 , Kovin S Naidoo  127 , K M Venkat Narayan  23 , Chakib Nejjari  128 , Marie Ng  2 , Jean de Dieu Ngirabega  129 , Mark J Nieuwenhuijsen  130 , Luke Nyakarahuka  131 , Takayoshi Ohkubo  132 , Saad B Omer  23 , Angel J Paternina Caicedo  133 , Victoria Pillay-van Wyk  90 , Dan Pope  35 , Farshad Pourmalek  134 , Dorairaj Prabhakaran  135 , Sajjad U R Rahman  136 , Saleem M Rana  137 , Robert Quentin Reilly  138 , David Rojas-Rueda  130 , Luca Ronfani  122 , Lesley Rushton  139 , Mohammad Yahya Saeedi  17 , Joshua A Salomon  57 , Uchechukwu Sampson  88 , Itamar S Santos  109 , Monika Sawhney  140 , Jürgen C Schmidt  53 , Marina Shakh-Nazarova  91 , Jun She  141 , Sara Sheikhbahaei  60 , Kenji Shibuya  142 , Hwashin Hyun Shin  143 , Kawkab Shishani  144 , Ivy Shiue  145 , Inga Dora Sigfusdottir  146 , Jasvinder A Singh  147 , Vegard Skirbekk  97 , Karen Sliwa  148 , Sergey S Soshnikov  149 , Luciano A Sposato  150 , Vasiliki Kalliopi Stathopoulou  151 , Konstantinos Stroumpoulis  152 , Karen M Tabb  153 , Roberto Tchio Talongwa  154 , Carolina Maria Teixeira  155 , Abdullah Sulieman Terkawi  156 , Alan J Thomson  157 , Andrew L Thorne-Lyman  158 , Hideaki Toyoshima  159 , Zacharie Tsala Dimbuene  160 , Parfait Uwaliraye  161 , Selen Begüm Uzun  32 , Tommi J Vasankari  162 , Ana Maria Nogales Vasconcelos  163 , Vasiliy Victorovich Vlassov  164 , Stein Emil Vollset  97 , Stephen Waller  165 , Xia Wan  166 , Scott Weichenthal  143 , Elisabete Weiderpass  167 , Robert G Weintraub  168 , Ronny Westerman  125 , James D Wilkinson  169 , Hywel C Williams  170 , Yang C Yang  171 , Gokalp Kadri Yentur  32 , Paul Yip  172 , Naohiro Yonemoto  173 , Mustafa Younis  174 , Chuanhua Yu  175 , Kim Yun Jin  176 , Maysaa El Sayed Zaki  177 , Shankuan Zhu  178 , Theo Vos  2 , Alan D Lopez  14 , Christopher J L Murray  2
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Free PMC article
Multicenter Study

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

Haidong Wang et al. Lancet. .
Free PMC article

Erratum in

  • Lancet. 2014 Sep 13;384(9947):956

Abstract

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.

Figures

Figure 1
Figure 1
Child mortality estimation process for the Global Burden of Diseases, Injuries, and Risk Factors Study 2013
Figure 2
Figure 2. Global under-5 mortality rate and rate of change, 1970–2013
(A) Global under-5 mortality, 1970–2013. (B) Annualised rate of change in global child mortality, 1970–2013.
Figure 3
Figure 3. Global annualised rate of change in under-5 mortality rate (%) from 1990–2000, and 2000–13
Solid line shows the equivalence line between the two periods. Dashed lines show the Millenium Development Goal 4 target rate of 4·4% per year. We excluded North Korea from the figure because of substantially higher rates of change that distort the scales in the figure.CHN=China. EST=Estonia. IDN=Indonesia. GUY=Guyana. ETH=Ethiopia. TLS=Timor-Leste. IND=India. NER=Niger. PAK=Pakistan. NGA=Nigeria. MNE=Montenegro. ZAF=South Africa. COG=Congo. TON=Tonga. SWZ =Swaziland. BWA=Botswana. BHS=The Bahamas. MLT=Malta. FJI=Fiji.
Figure 4
Figure 4. Change in the number of deaths comparing 2013 with 1990
Change due to income per person, maternal education, HIV child death rate, shift in secular trend, births, and unexplained factors for seven Global Burden of Disease super-regions.
Figure 5
Figure 5. Countries with statistically significant differences between the observed rate of decline in under-5 mortality between 2000 and 2013, compared with the expected rate of decline on the basis of income, education, shift in secular trend, and HIV death rates in the absence of intervention
ATG=Antigua and Barbuda. LCA=Saint Lucia. VCT=Saint Vincent and the Grenadines. TTO=Trinidad and Tobago. TLS=Timor-Leste. FSM=Federated States of Micronesia.
Figure 6
Figure 6. Projected global under-5 deaths for four scenarios, 2013–30
Scenarios have been defined by the distribution of observed rates of change 2000 to 2013.
Figure 7
Figure 7. Projected under-5 mortality rate in 2030, on the basis of the observed rate of change for each country, 2000–13
ATG=Antigua and Barbuda. LCA=Saint Lucia. VCT=Saint Vincent and the Grenadines. TTO=Trinidad and Tobago. TLS=Timor-Leste. FSM=Federated States of Micronesia.
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