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Lancet Child Survival 10mill Dying[1]

Lancet Child Survival 10mill Dying[1]

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CHILD SURVIVAL I

Child survival I

Where and why are 10 million children dying every year?

Robert E Black, Saul S Morris, Jennifer Bryce More than 10 million children die each year, most from preventable causes and almost all in poor countries. Six countries account for 50% of worldwide deaths in children younger than 5 years, and 42 countries for 90%. The causes of death differ substantially from one country to another, highlighting the need to expand understanding of child health epidemiolog
CHILD SURVIVAL I

Child survival I

Where and why are 10 million children dying every year?

Robert E Black, Saul S Morris, Jennifer Bryce More than 10 million children die each year, most from preventable causes and almost all in poor countries. Six countries account for 50% of worldwide deaths in children younger than 5 years, and 42 countries for 90%. The causes of death differ substantially from one country to another, highlighting the need to expand understanding of child health epidemiolog

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09/28/2010

 
For personal use. Only reproduce with permission from The Lancet.
CHILD SURVIVAL I
2226
THELANCET
• 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.
1,2
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.
1
In 1990–2001, the number of child deathsfell by 1·1% every year, compared with 2·5% per yearduring 1960–90.
3
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.
1
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.
1
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.
4
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.
4
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.
4
Unfortunately,investments in health systems and interventions necessaryto achieve such a reduction in the 1990s were not
Lancet
2003;
361:
2226–34
See Commentary page 2172
Johns Hopkins Bloomberg School of Public Health, Baltimore, MD,USA
(Prof R E Black
MD
)
; Department of Epidemiology andPopulation Health, London School of Hygiene and TropicalMedicine, London, UK
(S S Morris
PhD
)
; and 25 rue du Bugnon,St Genis-Pouilly, 10630 France
(JBryce
EdD
)
Correspondence to
: Prof Robert E Black, Department of InternationalHealth, Johns Hopkins Bloomberg School of Public Health,Baltimore, MD 21205, USA(e-mail: rblack@jhsph.edu)
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.
4
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.
5
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.
6
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.
7
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.
7
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.
Search strategy
The search strategy for the model used to estimateproportionate causes of death has been described.
32
Estimates of the importance of risk factors were taken frompublished results.
12
For our comorbidity analyses we alsocontacted researchers and directors of demographicsurveillance areas in low-income and middle-income countries.
 
For personal use. Only reproduce with permission from The Lancet.
Risk factors for child mortality
Unhygienic and unsafe environments place children at riskof death.
2,12
Ingestion of unsafe water, inadequateavailability of water for hygiene, and lack of access tosanitation contribute to about 1·5 million child deaths andaround 88% of deaths from diarrhoea.
2,12
Other health-related behaviours, such as birth spacing, are alsoimportant risk factors for child mortality.
13
Infants aged 0–5 months who are not breastfed haveseven-fold and five-fold increased risks of death fromdiarrhoea and pneumonia, respectively, compared withinfants who are exclusively breastfed.
14
At the same age,non-exclusive rather than exclusive breastfeeding results inmore than two-fold increased risks of dying fromdiarrhoea or pneumonia.
15
6–11-month-old infants whoare not breastfed also have an increased risk of suchdeaths.
16
Child deaths are commonly the result of several riskfactors. In the future, the joint effects of two or more riskfactors on each underlying or associated cause of deathshould be estimated together.
17
Thus, the total effect of interventions to prevent or mitigate the effects of varioussets of risk factors could be established.
Underlying causes of death
WHO’s work on the global burden of disease, consistentwith the International Classification of Diseases (ICD),
CHILD SURVIVAL I
THELANCET
• Vol 361 • June 28, 2003 • www.thelancet.com
2227data in many countries can make this task difficult, soassessment of the needs and possible interventionsfor more homogeneous groups of countries is alsoworthwhile.A few countries account for a very large proportion of all child deaths. In fact, half of worldwide deaths inchildren younger than 5 years occur in only six countries,and 90% in 42 countries (table 1).
7–9
However, the orderof countries differs when ranked by child mortality raterather than by number of deaths, in that countries in sub-Saharan Africa with quite small population sizes dominatethe highest ranks (table 1); thus, the first 42 countriesranked by mortality rate constitute only 44% of childdeaths worldwide.Figure 1 shows that deaths are concentrated in someregions, in particular south Asia and sub-Saharan Africa.Even within countries, spatial variation in mortality ratescan be large. In India, for example, the 1998–99 nationalfamily health survey found that mortality rates for childrenyounger than 5 years varied from 18·8 per 1000 births inKerala to 137·6 per 1000 in Madhya Pradesh.
10
Althoughmost child deaths in these countries occur inrural areas, urban slum populations can have especiallyhigh child mortality rates. For example, children in theslums of Nairobi, Kenya, have mortality rates muchhigher than rural Kenyan children (150·6 per 1000livebirths
vs
113·0, respectively).
11
Countries ranked by total Number of Under-5-year Countries ranked by under-Under-5-year mortality rate Number of childnumber of child deathschild deaths
*
mortality-rate rank
5-year mortality rate(per 1000 births)deaths rank
India240200054Sierra Leone31636Nigeria83400017Niger27012China78400088Angola26011Pakistan56500043Afghanistan2578D R Congo4840009Liberia23551Ethiopia47200021Mali23316Bangladesh34300057·5Somalia22522Afghanistan2510004Guinea-Bissau21570Tanzania22300023D R Congo2055Indonesia21800076·5Zambia20227Angola1690003Chad20033Niger1560002Mozambique20013Mozambique15500011·5Burkina Faso19820Uganda14500036Burundi19044Myanmar13200043Malawi18825Mali1280006Rwanda18742Brazil12700092Nigeria1842Kenya12500039Mauritania18359Sudan11600045·5Central African Republic18054Burkina Faso10400013Guinea17541Iraq10400034Ethiopia1746Somalia1000007Côte dIvoire17324Yemen9700043Tanzania1659Côte dIvoire9700022Benin16046Malawi9600015Equatorial Guinea15689Madagascar9300030·5Cameroon15428Zambia8800010Djibouti14688Cameroon8300026Swaziland14285Philippines8200088Togo14255South Africa7700066·5Senegal13945Nepal7600054Madagascar13926Egypt7600080Cambodia13539Chad7300011·5Lesotho13373Iran7100082·5Iraq13021Mexico70000101·5Gambia12879Sierra Leone690001Uganda12714Turkey6600080Haiti12552Ghana6500049East Timor12490Cambodia6300032Kenya12018Viet Nam6300091Zimbabwe11743Guinea6200020Eritrea11463Rwanda 5400016Yemen11023
*Number of deaths estimated by multiplying the number of livebirths
8
by the under-5-year mortality rate
7
and by a life-table based adjustment factor that slightlyreduces the number of deaths if the yearly number of births has increased over the previous quinquennium and slightly increases it if births have fallen.
9
Decimalplaces indicate that two countries were equally ranked.
Table 1:
Countries ranked by total child (under-5-year) deaths or by under-5-year mortality rates in 2000
 
For personal use. Only reproduce with permission from The Lancet.
CHILD SURVIVAL I
2228
THELANCET
• Vol 361 • June 28, 2003 • www.thelancet.com
    P    A    C    I    F    I    C    O    C    E    A    N    I    N    D    I    A    N    O    C    E    A    N    A    T    L    A    N    T    I    C    O    C    E    A    N    P    A    C    I    F    I    C    O    C    E    A    N
Figure 1:
Worldwide distribution of child deaths
Each dot represents 5000 deaths.
7–9
   O  x   f  o  r   d   C  a  r   t  o  g  r  a  p   h  e  r  s   2   0   0   3

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