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CHILD SURVIVAL I
• Vol 361 • June 28, 2003 • www.thelancet.com
Substantial reductions in child mortality occurred in low-income and middle-income countries in the late 20thcentury, but more than 10 million children younger than5 years still die every year.
In this article, the first in aseries of five, we consider reasons for these deaths andprovide recommendations for how they can be prevented.Rates of decline in worldwide child mortality peaked inabout 1980.
In 1990–2001, the number of child deathsfell by 1·1% every year, compared with 2·5% per yearduring 1960–90.
Although this deceleration might beexpected in areas that had already achieved low rates of mortality, such slowing has also occurred in high-rateregions. Sub-Saharan Africa had the highest childmortality in 1970–74, but in the years since has had theslowest fall in rate.
South Asia also had a high rate of child deaths in the 1970s, and despite a 50% drop inmortality, almost one in ten children in this region stilldies before their fifth birthday.
Child mortality varies among world regions, and thesedifferences are large and increasing. In 1990, there were180 deaths per 1000 livebirths in sub-Saharan Africa andonly 9 per 1000 in industrialised countries—a 20-folddifference.
In 2000, this gap had increased to 29-foldwith mortality rates of 175 and 6 per 1000 children insub-Saharan Africa and industrialised countries,respectively.
The World Summit for Children in 1990 called for aworldwide reduction in child mortality to below 70 deathsper 1000 livebirths (or a one-third reduction if this yieldeda lower mortality rate) by the year 2000.
Unfortunately,investments in health systems and interventions necessaryto achieve such a reduction in the 1990s were not
See Commentary page 2172
Johns Hopkins Bloomberg School of Public Health, Baltimore, MD,USA
(Prof R E Black
; Department of Epidemiology andPopulation Health, London School of Hygiene and TropicalMedicine, London, UK
(S S Morris
; and 25 rue du Bugnon,St Genis-Pouilly, 10630 France
: Prof Robert E Black, Department of InternationalHealth, Johns Hopkins Bloomberg School of Public Health,Baltimore, MD 21205, USA(e-mail: firstname.lastname@example.org)
commensurate with needs. The mortality reduction targetwas reached for only five of 55 countries with an under-5-year mortality rate of 100 or more in 1990.
In 2002, as part of the millennium development goalsfor health, nations pledged to ensure a two-thirdsreduction in child mortality by 2015, from the base year1990.
In addition to setting such a goal, the global publichealth community must critically assess how it can beaccomplished. A realistic picture of a country’sepidemiological profile and the capabilities of its healthsystem is needed before appropriate public healthinterventions can be developed and implemented.Development of these interventions also requires anunderstanding of the determinants of child mortality.These determinants include, at the most distant level,socioeconomic factors, such as income, social status, andeducation, which work through an intermediate level of environmental and behavioural risk factors.
These riskfactors, in turn, lead to the proximal causes of death(nearer in time to the terminal event), such asundernutrition, infectious diseases, and injury. In thispaper, we will focus on proximal causes of death and onselected environmental and behavioural risk factors. Thefourth article in this series will address the socioeconomicdeterminants of child mortality.
Where do most child deaths occur?
The estimate for global child deaths in 2000 is10·8million.
In this series, data from 2000 will be usedthroughout because they are most complete for thisperiod and little has changed in the past 2 years. About41% of child deaths occur in sub-Saharan Africa andanother 34% in south Asia.
Because there is substantialvariation in death rates within these regions, planningfor health interventions should take place at a nationallevel. The incomplete and unreliable nature of these
Where and why are 10 million children dying every year?
Robert E Black, Saul S Morris, Jennifer Bryce
Child survival I
More than 10 million children die each year, most from preventable causes and almost all in poor countries. Sixcountries account for 50% of worldwide deaths in children younger than 5 years, and 42 countries for 90%. The causesof death differ substantially from one country to another, highlighting the need to expand understanding of child healthepidemiology at a country level rather than in geopolitical regions. Other key issues include the importance of undernutrition as an underlying cause of child deaths associated with infectious diseases, the effects of multipleconcurrent illnesses, and recognition that pneumonia and diarrhoea remain the diseases that are most oftenassociated with child deaths. A better understanding of child health epidemiology could contribute to more effectiveapproaches to saving children’s lives.
The search strategy for the model used to estimateproportionate causes of death has been described.
Estimates of the importance of risk factors were taken frompublished results.
For our comorbidity analyses we alsocontacted researchers and directors of demographicsurveillance areas in low-income and middle-income countries.