Skip to 0 minutes and 13 seconds JOY LAWN: Progress for child survival– how many children die before their fifth birthday? Well, in 1990, at the baseline of the Millennium Development Goals, more than 12.7 million children died every year. And one of the most remarkable successes of global development is that now, at the end of the Millennium Development Goal era in 2015, around six million children die. The optimist here says this is amazing because despite more children being born every year, the number of child deaths has more than halved in this time period. But let’s pause to remember that each of these six million such a huge number, that’s a child that died, in most cases, from preventable conditions.
Skip to 1 minute and 5 seconds So as we flip to looking at what’s happened for rates of child mortality worldwide since 1990, we started with child mortality rate of around 90. We’ve now seen that halve. So it’s taken us around 25 years to halve the risk of child death. The optimist here says, that’s remarkable. We’ve halved. The pessimists says, well, actually our target was 2/3 reduction. We still have a huge risk of death. So this is around 5% of children around the world who die before they reach their fifth birthday. And so how do we change that? How do we go forward?
Skip to 1 minute and 47 seconds And one critical point to note here is that over this 25-year time period, in fact, most of the change has been in the last 10 years, and we’re still speeding up over the last five years. But the time for death has really changed during this time period. So despite this remarkable progress for under five mortality, if we look at risk of death in the first month of life, so this is the two pink lines at the bottom, what we can see is this is much flatter. So this is deaths in neonatal period, the first month of life, and it’s been much slower. So the pessimist says here that then neonatal mortality is the barrier.
Skip to 2 minutes and 33 seconds But the optimists says, actually, we’ve barely just started to focus on neonatal mortality. We have lots in our tool kit to be able to prevent neonatal deaths. And with the same focus that we’ve had on the deaths after the neonatal period, particularly for infections, we could see great progress for neonatal deaths. Before leaving this chart for child mortality rates, I just want to flag the two different lines. So if you look at these two different lines the top blue line is the United Nations estimates, and the next is from the International Health Metrics and Evaluation unit in Seattle. And actually these line are very similar at global level, both for under five and for neonatal.
Skip to 3 minutes and 17 seconds So we shouldn’t be fighting about where the data is coming from. The good news is there are more data, and the uncertainty is changed. And this is much clearer at global level, but at some countries, the differences really remain. So, for example, according to the UN data, Tanzania is on track for under five mortality and has met MDG 4, but according to HME data, it hasn’t, so there remain differences at country level, and improving the data and using that data for accountability is an important message out to the MDGs, and something we need to keep traction for. But if we move forward to say, what happens now?
Skip to 3 minutes and 54 seconds So we looked at this chart during the module on the newborns, and we saw that and it’s really critical to have a target for accelerating change for the neonatal mortality part, the blue lines at the bottom. We saw that a target has been set for reaching under five mortality rate in every country of 22 or less by 2030. And I want to flag that this means that we have now said that we are aiming to take 15 years to halve the risk of child death. It’s taken us 25 years to get to where we are, but we had a pretty slow start. We didn’t do what we should have been doing during the ’90s for child survival.
Skip to 4 minutes and 36 seconds But this is now 15 years to close this gap and go forward– so more ambitious. And to do that we need to say, where do children die, and how do we use the data to change child survival? So the biggest numbers of deaths are where the biggest births are. And currently, around 25% of births are in Africa. As we go forward, even assuming ongoing increases in family planning use in Africa, by 2030, one in three of the world’s births will be born in Africa. So this is still lower than the number of births in Asia.
Skip to 5 minutes and 15 seconds But because of greater progress in South Asia, both for reducing births but for reducing deaths, unless we change what is happening, both for addressing family planning and unmet need and child mortality risk, 60% of child deaths will be in Africa by the year 2030. So still around 15% of the world’s population but around 60% percent of child deaths. So this is absolutely critical that we do something about this. And I’m an African, and I think that we can and must do something about this. We shouldn’t just accept that Africa carries such a heavy disproportionate burden compared both to births and to global population. Where’s the highest risk of child mortality?
Skip to 6 minutes and 8 seconds And these two maps from the World Health Organisation show us where we were in 1990 for of the risk of child death in each country and where we are with the most recent data. If we look at 1990, the dark red countries are those where more than 20% of children died by their fifth birthday. So the good news, the more recent data is that we don’t have any countries where more than 20% of children are dying by their fifth birthday. However we can still see that this orange colour is where more than 10% of children die, so more than 100 per 1,000 births, and all of these orange countries are in Africa.
Skip to 6 minutes and 57 seconds And, in fact, most of these places with humanitarian emergencies, fragile states, a number of countries, where, for example, Ebola may have pushed progress backwards. Liberia was making great progress, and some of that ground has been lost at the moment. So as we move forward not just more focus on Africa, but critically on emergency settings, and these data are still national averages. So if we look at sub-national, and look by income quintile, look by urban/rural, there are huge disparities still for women and children in these countries. So what do children die of? Here is a cause of death pie that you will probably be quite familiar with now.
Skip to 7 minutes and 49 seconds And if we look at this, we have already focused during the newborn module on the 44%, in fact, more than 44% of deaths that are in the neonatal period, the first month of life. But if we look at the child deaths as a whole, obviously, this critical focus on newborn deaths and a shift to preterm birth complications is very important. And what we should note here that over the time period of the MDGs, the median day of death has shifted. A very elegant analysis from Brazil shows us that around 1980, the median day of death was day 30. But by around 2007, the median day of death is day three.
Skip to 8 minutes and 40 seconds So as we move forward, that focus towards the time of birth is critical, and things we have to do are different. But over all on this pie, it is still true that the leading grouped cause for child deaths is still infections, and we’ll be looking forward in this module at what has changed, what needs to change more, and how to close this gap for infection deaths in children, particularly pneumonia and diarrhoea, but also for malaria and ending AIDS. And then I want to highlight the other slice here. So other is in fact 15% of child deaths. And this hides congenital disorders. It hides some of the noncommunicable conditions and child cancers, and these are critical.
Skip to 9 minutes and 32 seconds And what we don’t see is the underlying challenge of undernutrition. So, particularly for children with infections, many of these are a amongst children who are undernourished, and we also have the increasing scurge of childhood obesity that will be contributing to the noncommunicable diseases. So in the rest of this module, we will be digging into these causes of death. What do we do for infections? What have we learned? What do we do differently? What are the things around nutrition and stunting that are critical, and how can we go forward? What are the research gaps and the data for action and the solutions we have to change child survival around the world?
How many children die, where, and from what causes?
In 1990, around 12.7 million children died before reaching their 5th birthday. Millennium Development Goal (MDG) 4 aimed to reduce this by two-thirds by the end of 2015. In this step, Professor Joy Lawn discusses the progress that has been made.
We now know that mortality for under-fives has halved, from an average of approximately 90 deaths per 1000 live births to 46 against an MDG target of about 30. Progress has been much slower for neonatal mortality, with around 20 babies per 1000 live births dying in their first month of life. Looking ahead, the renewed targets for 2030 are to reduce under-five mortality to 22 or less, and neonatal mortality to 12 or less.
Under-five mortality is highly concentrated in Africa, and will become more so by 2030. It is estimated that by 2030, one out of three births will be in Africa along with 60% of child deaths.
© London School of Hygiene & Tropical Medicine