Search

Children are not born equal in their likelihood of survival. The risk of mortality is highest during and shortly after birth. In the immediate postnatal period and beyond, perinatal events, nutrition, infections, family and environmental exposures, and health services largely determine the risk of death. We argue that current public health programmes do not fully acknowledge this spectrum of risk or respond accordingly. As a result, opportunities to improve the care, survival, and development of children in resource-poor settings are overlooked. Children at high risk of mortality are underidentified and commonly treated using guidelines that do not differentiate care according to the magnitude or drivers of those risks. Children at low risk of mortality are often provided with more intensive care than needed, disproportionately using limited health-care resources with minimal or no benefits. Declines in newborn, infant, and child mortality rates globally are slowing, and further reductions are likely to be incrementally more difficult to achieve once simple, high impact interventions have been universally implemented. Currently, 63 countries have rates of neonatal mortality that are off track to meet the Sustainable Development Goal 2030 target of 12 deaths per 1000 livebirths or less, and 54 countries have rates of mortality in children younger than 5 years that are off track to meet the target of 25 deaths per 1000 livebirths or less. If these targets are to be met, a change of approach is needed to address infant and child mortality and for health-care systems to more efficiently address residual mortality. [ABSTRACT FROM AUTHOR]

Background: India has made substantial progress in improving child survival over the past few decades, but a comprehensive understanding of child mortality trends at disaggregated geographical levels is not available. We present a detailed analysis of subnational trends of child mortality to inform efforts aimed at meeting the India National Health Policy (NHP) and Sustainable Development Goal (SDG) targets for child mortality.Methods: We assessed the under-5 mortality rate (U5MR) and neonatal mortality rate (NMR) from 2000 to 2017 in 5 × 5 km grids across India, and for the districts and states of India, using all accessible data from various sources including surveys with subnational geographical information. The 31 states and groups of union territories were categorised into three groups using their Socio-demographic Index (SDI) level, calculated as part of the Global Burden of Diseases, Injuries, and Risk Factors Study on the basis of per-capita income, mean education, and total fertility rate in women younger than 25 years. Inequality between districts within the states was assessed using the coefficient of variation. We projected U5MR and NMR for the states and districts up to 2025 and 2030 on the basis of the trends from 2000 to 2017 and compared these projections with the NHP 2025 and SDG 2030 targets for U5MR (23 deaths and 25 deaths per 1000 livebirths, respectively) and NMR (16 deaths and 12 deaths per 1000 livebirths, respectively). We assessed the causes of child death and the contribution of risk factors to child deaths at the state level.Findings: U5MR in India decreased from 83·1 (95% uncertainty interval [UI] 76·7-90·1) in 2000 to 42·4 (36·5-50·0) per 1000 livebirths in 2017, and NMR from 38·0 (34·2-41·6) to 23·5 (20·1-27·8) per 1000 livebirths. U5MR varied 5·7 times between the states of India and 10·5 times between the 723 districts of India in 2017, whereas NMR varied 4·5 times and 8·0 times, respectively. In the low SDI states, 275 (88%) districts had a U5MR of 40 or more per 1000 livebirths and 291 (93%) districts had an NMR of 20 or more per 1000 livebirths in 2017. The annual rate of change from 2010 to 2017 varied among the districts from a 9·02% (95% UI 6·30-11·63) reduction to no significant change for U5MR and from an 8·05% (95% UI 5·34-10·74) reduction to no significant change for NMR. Inequality between districts within the states increased from 2000 to 2017 in 23 of the 31 states for U5MR and in 24 states for NMR, with the largest increases in Odisha and Assam among the low SDI states. If the trends observed up to 2017 were to continue, India would meet the SDG 2030 U5MR target but not the SDG 2030 NMR target or either of the NHP 2025 targets. To reach the SDG 2030 targets individually, 246 (34%) districts for U5MR and 430 (59%) districts for NMR would need a higher rate of improvement than they had up to 2017. For all major causes of under-5 death in India, the death rate decreased between 2000 and 2017, with the highest decline for infectious diseases, intermediate decline for neonatal disorders, and the smallest decline for congenital birth defects, although the magnitude of decline varied widely between the states. Child and maternal malnutrition was the predominant risk factor, to which 68·2% (65·8-70·7) of under-5 deaths and 83·0% (80·6-85·0) of neonatal deaths in India could be attributed in 2017; 10·8% (9·1-12·4) of under-5 deaths could be attributed to unsafe water and sanitation and 8·8% (7·0-10·3) to air pollution.Interpretation: India has made gains in child survival, but there are substantial variations between the states in the magnitude and rate of decline in mortality, and even higher variations between the districts of India. Inequality between districts within states has increased for the majority of the states. The district-level trends presented here can provide crucial guidance for targeted efforts needed in India to reduce child mortality to meet the Indian and global child survival targets. District-level mortality trends along with state-level trends in causes of under-5 and neonatal death and the risk factors in this Article provide a comprehensive reference for further planning of child mortality reduction in India.Funding: Bill & Melinda Gates Foundation; and Indian Council of Medical Research, Department of Health Research, Ministry of Health and Family Welfare, Government of India. [ABSTRACT FROM AUTHOR]

Background: Previous analyses of democracy and population health have focused on broad measures, such as life expectancy at birth and child and infant mortality, and have shown some contradictory results. We used a panel of data spanning 170 countries to assess the association between democracy and cause-specific mortality and explore the pathways connecting democratic rule to health gains.Methods: We extracted cause-specific mortality and HIV-free life expectancy estimates from the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 and information on regime type from the Varieties of Democracy project. These data cover 170 countries and 46 years. From the Financing Global Health database, we extracted gross domestic product (GDP) per capita, also covering 46 years, and Development Assistance for Health estimates starting from 1990 and domestic health spending estimates starting from 1995. We used a diverse set of empirical methods-synthetic control, within-country variance decomposition, structural equation models, and fixed-effects regression-which together provide a robust analysis of the association between democratisation and population health.Findings: HIV-free life expectancy at age 15 years improved significantly during the study period (1970-2015) in countries after they transitioned to democracy, on average by 3% after 10 years. Democratic experience explains 22·27% of the variance in mortality within a country from cardiovascular diseases, 16·53% for tuberculosis, and 17·78% for transport injuries, and a smaller percentage for other diseases included in the study. For cardiovascular diseases, transport injuries, cancers, cirrhosis, and other non-communicable diseases, democratic experience explains more of the variation in mortality than GDP. Over the past 20 years, the average country's increase in democratic experience had direct and indirect effects on reducing mortality from cardiovascular disease (-9·64%, 95% CI -6·38 to -12·90), other non-communicable diseases (-9·14%, -4·26 to -14·02), and tuberculosis (-8·93%, -2·08 to -15·77). Increases in a country's democratic experience were not correlated with GDP per capita between 1995 and 2015 (ρ=-0·1036; p=0·1826), but were correlated with declines in mortality from cardiovascular disease (ρ=-0·3873; p<0·0001) and increases in government health spending (ρ=0·4002; p<0·0001). Removal of free and fair elections from the democratic experience variable resulted in loss of association with age-standardised mortality from non-communicable diseases and injuries.Interpretation: When enforced by free and fair elections, democracies are more likely than autocracies to lead to health gains for causes of mortality (eg, cardiovascular diseases and transport injuries) that have not been heavily targeted by foreign aid and require health-care delivery infrastructure. International health agencies and donors might increasingly need to consider the implications of regime type in their efforts to maximise health gains, particularly in the context of ageing populations and the growing burden of non-communicable diseases.Funding: Bloomberg Philanthropies and the Bill & Melinda Gates Foundation. [ABSTRACT FROM AUTHOR]

Variations in mortality in the country are known at the macro level, and now the India State-Level Disease Burden Initiative Child Mortality Collaborators[1] have mapped neonatal and under-5 mortality rates from 2000 to 2017 for every district in India, going down to geospatial grids as small as 5 km × 5 km. In The Lancet, the study authors report that the under-5 mortality rate (U5MR) in India decreased from 83-1 deaths (95% uncertainty interval 76-7-90-1) in 2000 to 42-4 deaths (36-5-50-0) per 1000 livebirths in 2017, and the neonatal mortality rate (NMR) decreased from 38-0 deaths (34-2-41-6) to 23-5 deaths (20-1-27-8) per 1000 livebirths. [Extracted from the article]

Background: A substantial portion of child deaths in Africa take place in countries with recent history of armed conflict and political instability. However, the extent to which armed conflict is an important cause of child mortality, especially in Africa, remains unknown.Methods: We matched child survival with proximity to armed conflict using information in the Uppsala Conflict Data Program Georeferenced Events Dataset on the location and intensity of armed conflict from 1995 to 2015 together with the location, timing, and survival of infants younger than 1 year (primary outcome) in 35 African countries. We measured the increase in mortality risk for infants exposed to armed conflicts within 50 km in the year of birth and, to study conflicts' extended health risks, up to 250 km away and 10 years before birth. We also examined the effects of conflicts of varying intensity and chronicity (conflicts lasting several years), and effect heterogeneity by residence and sex of the child. We then estimated the number and portion of deaths of infants younger than 1 year related to conflict.Findings: We identified 15 441 armed conflict events that led to 968 444 combat-related deaths and matched these data with 1·99 million births and 133 361 infant deaths (infant mortality of 67 deaths per 1000 births) between 1995 and 2015. A child born within 50 km of an armed conflict had a risk of dying before reaching age 1 year of 5·2 per 1000 births higher than being born in the same region during periods without conflict (95% CI 3·7-6·7; a 7·7% increase above baseline). This increased risk of dying ranged from a 3·0% increase for armed conflicts with one to four deaths to a 26·7% increase for armed conflicts with more than 1000 deaths. We find evidence of increased mortality risk from an armed conflict up to 100 km away, and for 8 years after conflicts, with cumulative increase in infant mortality two to four times higher than the contemporaneous increase. In the entire continent, the number of infant deaths related to conflict from 1995 to 2015 was between 3·2 and 3·6 times the number of direct deaths from armed conflicts.Interpretation: Armed conflict substantially and persistently increases infant mortality in Africa, with effect sizes on a scale with malnutrition and several times greater than existing estimates of the mortality burden of conflict. The toll of conflict on children, who are presumably not combatants, underscores the indirect toll of conflict on civilian populations, and the importance of developing interventions to address child health in areas of conflict.Funding: The Doris Duke Charitable Foundation, and the Centre for Global Child Health at the Hospital for Sick Children. [ABSTRACT FROM AUTHOR]

Background: Documentation of the demographic and geographical details of changes in cause-specific neonatal (younger than 1 month) and 1-59-month mortality in India can guide further progress in reduction of child mortality. In this study we report the changes in cause-specific child mortality between 2000 and 2015 in India.Methods: Since 2001, the Registrar General of India has implemented the Million Death Study (MDS) in 1·3 million homes in more than 7000 randomly selected areas of India. About 900 non-medical surveyors do structured verbal autopsies for deaths recorded in these homes. Each field report is assigned randomly to two of 404 trained physicians to classify the cause of death, with a standard process for resolution of disagreements. We combined the proportions of child deaths according to the MDS for 2001-13 with annual UN estimates of national births and deaths (partitioned across India's states and rural or urban areas) for 2000-15. We calculated the annual percentage change in sex-specific and cause-specific mortality between 2000 and 2015 for neonates and 1-59-month-old children.Findings: The MDS captured 52 252 deaths in neonates and 42 057 deaths at 1-59 months. Examining specific causes, the neonatal mortality rate from infection fell by 66% from 11·9 per 1000 livebirths in 2000 to 4·0 per 1000 livebirths in 2015 and the rate from birth asphyxia or trauma fell by 76% from 9·0 per 1000 livebirths in 2000 to 2·2 per 1000 livebirths in 2015. At 1-59 months, the mortality rate from pneumonia fell by 63% from 11·2 per 1000 livebirths in 2000 to 4·2 per 1000 livebirths in 2015 and the rate from diarrhoea fell by 66% from 9·4 per 1000 livebirths in 2000 to 3·2 per 1000 livebirths in 2015 (with narrowing girl-boy gaps). The neonatal tetanus mortality rate fell from 1·6 per 1000 livebirths in 2000 to less than 0·1 per 1000 livebirths in 2015 and the 1-59-month measles mortality rate fell from 3·3 per 1000 livebirths in 2000 to 0·3 per 1000 livebirths in 2015. By contrast, mortality rates for prematurity or low birthweight rose from 12·3 per 1000 livebirths in 2000 to 14·3 per 1000 livebirths in 2015, driven mostly by increases in term births with low birthweight in poorer states and rural areas. 29 million cumulative child deaths occurred from 2000 to 2015. The average annual decline in mortality rates from 2000 to 2015 was 3·3% for neonates and 5·4% for children aged 1-59 months. Annual declines from 2005 to 2015 (3·4% decline for neonatal mortality and 5·9% decline in 1-59-month mortality) were faster than were annual declines from 2000 to 2005 (3·2% decline for neonatal mortality and 4·5% decline in 1-59-month mortality). These faster declines indicate that India avoided about 1 million child deaths compared with continuation of the 2000-05 declines.Interpretation: To meet the 2030 Sustainable Development Goals for child mortality, India will need to maintain the current trajectory of 1-59-month mortality and accelerate declines in neonatal mortality (to >5% annually) from 2015 onwards. Continued progress in reduction of child mortality due to pneumonia, diarrhoea, malaria, and measles at 1-59 months is feasible. Additional attention to low birthweight is required.Funding: National Institutes of Health, Disease Control Priorities Network, Maternal and Child Epidemiology Estimation Group, and University of Toronto. [ABSTRACT FROM AUTHOR]

Background: Established in 2000, Millennium Development Goal 4 (MDG4) catalysed extraordinary political, financial, and social commitments to reduce under-5 mortality by two-thirds between 1990 and 2015. At the country level, the pace of progress in improving child survival has varied markedly, highlighting a crucial need to further examine potential drivers of accelerated or slowed decreases in child mortality. The Global Burden of Disease 2015 Study (GBD 2015) provides an analytical framework to comprehensively assess these trends for under-5 mortality, age-specific and cause-specific mortality among children under 5 years, and stillbirths by geography over time.Methods: Drawing from analytical approaches developed and refined in previous iterations of the GBD study, we generated updated estimates of child mortality by age group (neonatal, post-neonatal, ages 1-4 years, and under 5) for 195 countries and territories and selected subnational geographies, from 1980-2015. We also estimated numbers and rates of stillbirths for these geographies and years. Gaussian process regression with data source adjustments for sampling and non-sampling bias was applied to synthesise input data for under-5 mortality for each geography. Age-specific mortality estimates were generated through a two-stage age-sex splitting process, and stillbirth estimates were produced with a mixed-effects model, which accounted for variable stillbirth definitions and data source-specific biases. For GBD 2015, we did a series of novel analyses to systematically quantify the drivers of trends in child mortality across geographies. First, we assessed observed and expected levels and annualised rates of decrease for under-5 mortality and stillbirths as they related to the Soci-demographic Index (SDI). Second, we examined the ratio of recorded and expected levels of child mortality, on the basis of SDI, across geographies, as well as differences in recorded and expected annualised rates of change for under-5 mortality. Third, we analysed levels and cause compositions of under-5 mortality, across time and geographies, as they related to rising SDI. Finally, we decomposed the changes in under-5 mortality to changes in SDI at the global level, as well as changes in leading causes of under-5 deaths for countries and territories. We documented each step of the GBD 2015 child mortality estimation process, as well as data sources, in accordance with the Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER).Findings: Globally, 5·8 million (95% uncertainty interval [UI] 5·7-6·0) children younger than 5 years died in 2015, representing a 52·0% (95% UI 50·7-53·3) decrease in the number of under-5 deaths since 1990. Neonatal deaths and stillbirths fell at a slower pace since 1990, decreasing by 42·4% (41·3-43·6) to 2·6 million (2·6-2·7) neonatal deaths and 47·0% (35·1-57·0) to 2·1 million (1·8-2·5) stillbirths in 2015. Between 1990 and 2015, global under-5 mortality decreased at an annualised rate of decrease of 3·0% (2·6-3·3), falling short of the 4·4% annualised rate of decrease required to achieve MDG4. During this time, 58 countries met or exceeded the pace of progress required to meet MDG4. Between 2000, the year MDG4 was formally enacted, and 2015, 28 additional countries that did not achieve the 4·4% rate of decrease from 1990 met the MDG4 pace of decrease. However, absolute levels of under-5 mortality remained high in many countries, with 11 countries still recording rates exceeding 100 per 1000 livebirths in 2015. Marked decreases in under-5 deaths due to a number of communicable diseases, including lower respiratory infections, diarrhoeal diseases, measles, and malaria, accounted for much of the progress in lowering overall under-5 mortality in low-income countries. Compared with gains achieved for infectious diseases and nutritional deficiencies, the persisting toll of neonatal conditions and congenital anomalies on child survival became evident, especially in low-income and low-middle-income countries. We found sizeable heterogeneities in comparing observed and expected rates of under-5 mortality, as well as differences in observed and expected rates of change for under-5 mortality. At the global level, we recorded a divergence in observed and expected levels of under-5 mortality starting in 2000, with the observed trend falling much faster than what was expected based on SDI through 2015. Between 2000 and 2015, the world recorded 10·3 million fewer under-5 deaths than expected on the basis of improving SDI alone.Interpretation: Gains in child survival have been large, widespread, and in many places in the world, faster than what was anticipated based on improving levels of development. Yet some countries, particularly in sub-Saharan Africa, still had high rates of under-5 mortality in 2015. Unless these countries are able to accelerate reductions in child deaths at an extraordinary pace, their achievement of proposed SDG targets is unlikely. Improving the evidence base on drivers that might hasten the pace of progress for child survival, ranging from cost-effective intervention packages to innovative financing mechanisms, is vital to charting the pathways for ultimately ending preventable child deaths by 2030.Funding: Bill & Melinda Gates Foundation. [ABSTRACT FROM AUTHOR]

Background: In the past two decades, the under-5 mortality rate in China has fallen substantially, but progress with regards to the Millennium Development Goal (MDG) 4 at the subnational level has not been quantified. We aimed to estimate under-5 mortality rates in mainland China for the years 1970 to 2012.Methods: We estimated the under-5 mortality rate for 31 provinces in mainland China between 1970 and 2013 with data from censuses, surveys, surveillance sites, and disease surveillance points. We estimated under-5 mortality rates for 2851 counties in China from 1996 to 2012 with the reported child mortality numbers from the Annual Report System on Maternal and Child Health. We used a small area mortality estimation model, spatiotemporal smoothing, and Gaussian process regression to synthesise data and generate consistent provincial and county-level estimates. We compared progress at the county level with what was expected on the basis of income and educational attainment using an econometric model. We computed Gini coefficients to study the inequality of under-5 mortality rates across counties.Findings: In 2012, the lowest provincial level under-5 mortality rate in China was about five per 1000 livebirths, lower than in Canada, New Zealand, and the USA. The highest provincial level under-5 mortality rate in China was higher than that of Bangladesh. 29 provinces achieved a decrease in under-5 mortality rates twice as fast as the MDG 4 target rate; only two provinces will not achieve MDG 4 by 2015. Although some counties in China have under-5 mortality rates similar to those in the most developed nations in 2012, some have similar rates to those recorded in Burkina Faso and Cameroon. Despite wide differences, the inter-county Gini coefficient has been decreasing. Improvement in maternal education and the economic boom have contributed to the fall in child mortality; more than 60% of the counties in China had rates of decline in under-5 mortality rates significantly faster than expected. Fast reduction in under-5 mortality rates have been recorded not only in the Han population, the dominant ethnic majority in China, but also in the minority populations. All top ten minority groups in terms of population sizes have experienced annual reductions in under-5 mortality rates faster than the MDG 4 target at 4.4%.Interpretation: The reduction of under-5 mortality rates in China at the country, provincial, and county level is an extraordinary success story. Reductions of under-5 mortality rates faster than 8.8% (twice MDG 4 pace) are possible. Extremely rapid declines seem to be related to public policy in addition to socioeconomic progress. Lessons from successful counties should prove valuable for China to intensify efforts for those with unacceptably high under-5 mortality rates.Funding: National "Twelfth Five-Year" Plan for Science and Technology Support, National Health and Family Planning Commission of The People's Republic of China, Program for Changjiang Scholars and Innovative Research Team in University, the National Institute on Aging, and the Bill & Melinda Gates Foundation. [ABSTRACT FROM AUTHOR]

The article discusses a study which examined global trends in neonatal, infant and under-5 mortality from 1990 to 2013. Topics discussed include a reduction in child mortality rate, an increase in the number of child births in 2013 as compared to 1990, and developing countries expected to achieve the Millennium Development Goal 4 (MDG 4).

Background. Concern is growing that mortality and health in children and young people in the UK lags behind that of similar countries. Methods. We analysed death registry data provided to the WHO Mortality Database to compare UK mortality for children and young people aged 0-24 years with that of European Union member states (before May, 2004, excluding the UK, plus Australia, Canada, and Norway [the EU15+ countries]) from 1970 to 2008 using the WHO World Mortality Database. We grouped causes of death by Global Burden of Disease classification: communicable, nutritional, or maternal causes; non-communicable disorders; and injury. UK mortality trends were compared with quartiles of mortality in EU15+ countries. We used quasi-likelihood Poisson models to explore differences between intercepts and slopes between the UK and the EU15+ countries. Findings. In 1970, UK total mortality was in the best EU15+ quartile (<25th centile) for children and young people aged 1-24 years, with UK infant mortality similar to the EU15+ median. Subsequent mortality reductions in the UK were smaller than were those in the EU15+ countries in all age groups. By 2008, total mortality for neonates, infants, and children aged 1-4 years in the UK was in the worst EU15+ quartile (>75th centile). In 2008, UK annual excess mortality compared with the EU15+ median was 1035 deaths for infants and 134 for children aged 1-9 years. Mortality from non-communicable diseases in the UK fell from being roughly equivalent to the EU15+ median in 1970 to the worst quartile in all age groups by 2008, with 446 annual excess deaths from non-communicable diseases in the UK (280 for young people aged 10-24 years) in 2008. UK mortality from injury remained in the best EU15+ quartile for the study period in all age groups. Interpretation. The UK has not matched the gains made in child, adolescent, and young adult mortality by other comparable countries in the 40 years since 1970, particularly for infant deaths and mortality from noncommunicable diseases, including neuropsychiatric disorders. The UK needs to identify and address amenable social determinants and health system factors that lead to poor health outcomes for infants and for children and young people with chronic disorders. [ABSTRACT FROM AUTHOR]

The article focuses on a study which estimated the major causes of death in children younger than five years in China and India in 2008. Study authors estimated the rate of death in neonates aged zero to 27 days, and children aged one to 59 months. Causes of death that were discovered include preterm birth complications, birth asphyxia, sepsis and infectious diseases such as pneumonia, diarrhea and malaria. Study authors concluded that their findings could be use in selecting the focus of national programs and donor assistance. They added that the Millennium Development Goal of reducing child mortality can be achieved only if maternal, newborn and child health interventions will be adopted.

The article discusses a study which investigated the levels and trends in child mortality in 187 countries from 1970 to 2010. Study authors utilized a database containing 16,174 measurements of mortality in children younger than five years and used Gaussian process regression to generate estimates. They found that the worldwide mortality of children younger than five years decreased from 11.9 million in 1990 to 7.7 million in 2010. Global decline in neonatal mortality was 2.1 percent, 2.3 percent in postneonatal mortality and 2.2 percent in childhood mortality. Study authors also concluded that the declining rates of child mortality should be given more policy attention.

The article discusses ways in which community health workers can help reach the United Nations' Millennium Development Goals for world health child survival. Case management of childhood illness, preventive care, promotion of healthy behavior and community activism are all essential to child survival promotion. Community health workers require adequate pay, good training and specific tasks and goals. Community health programs must be evaluated for effectiveness and impact on child survival. The article presents a demographic assessment of community health workers and discusses what their role in specific interventions should be.

Background Only a few studies have investigated the link between human resources for health and health outcomes, and they arrive at different conclusions. We tested the strength and significance of density of human resources for health with improved methods and a new WHO dataset. Methods We did cross-country multiple regression analyses with maternal mortality rate, infant mortality rate, and under-five mortality rate as dependent variables. Aggregate density of human resources for health was an independent variable in one set of regressions; doctor and nurse densities separately were used in another set. We controlled for the effects of income, female adult literacy, and absolute income poverty. Findings Density of human resources for health is significant in accounting for maternal mortality rate, infant mortality rate, and under-five mortality rate (with elasticities ranging from -0.474 to -0.212, all p values ≤ 0.0036). The elasticities of the three mortality rates with respect to doctor density ranged from -0.386 to -0.174 (all p values ≤ 0.0029). Nurse density was not associated except in the maternal mortality rate regression without income poverty (p=0.0443). Interpretation In addition to other determinants, the density of human resources for health is important in accounting for the variation in rates of maternal mortality, infant mortality, and under-five mortality across countries. The effect of this density in reducing maternal mortality is greater than in reducing child mortality, possibly because qualified medical personnel can better address the illnesses that put mothers at risk. Investment in human resources for health must be considered as part of a strategy to achieve the Millennium Development Goals of improving maternal health and reducing child mortality. [ABSTRACT FROM AUTHOR]

Argues that the economic success in Uganda has come at the cost of social welfare programs. How the Ugandan government has taken the position that social welfare goals would be postponed until economic growth has reached some arbitrary optimum; Realities behind the economics; Increase in maternal mortality, infant mortality and in child mortality between 1995 and 2000; How 1/10th of the entire population are orphans and other children with no social support; Four possible reasons for declining social welfare; Belief that Uganda and other developing countries have embraced a myth of what free-market policy is; Call for the government to rethink its economic model before it leads to revolt and social instability. INSET: Panel: Effect of economic policy on maternal health.

Background HIV contributes substantially to child mortality, but factors underlying these deaths are inadequately described. With individual data from seven randomized mother-to-child transmission (MTCT) intervention trials, we estimate mortality in African children born to HIV-infected mothers and analyze selected risk factors. Methods Early HIV infection was defined as a positive HIV-PCR test before 4 weeks of age; and late infection by a negative PCR test at or after 4 weeks of age, followed by a positive test. Mortality rate was expressed per 1000 child-years. We investigated the effect of maternal health, infant HIV infection, feeding practices, and age at acquisition of infection on mortality assessed with Cox proportional hazards models, and allowed for random effects for trials grouped geographically. Findings 378 (11%) of 3468 children died. By age 1 year, an estimated 35.2% infected and 4.9% uninfected children will have died; by 2 years of age, 52.5% and 7.6% will have died, respectively. Mortality varied by geographical region, and was associated with maternal death (adjusted odds ratio 2.27, 95% CI 1.62-3.19), CD4+ cell counts <200 per L (1.91, 1.39-2.62), and infant HIV infection (8.16, 6.43-10.33). Mortality was not associated with either ever breastfeeding and never breastfeeding in either infected or uninfected children. In infected children, mortality was significantly lower for those with late infection than those with early infection (0.52, 0.39-0.70). This effect was also seen in analyses of survival from the age at infection (0.74, 0.55-0.99). Interpretation These findings highlight the necessity for timely antiretroviral care, for support for HIV-infected women and children in developing countries, and for assessment of prophylactic programs to prevent MTCT, including child mortality and infection averted. [ABSTRACT FROM AUTHOR]

The author comments on the paper "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" by H. Wang and colleagues. Topics discussed include a decline in mortality rate among under-5 children, a change in the structure of child deaths, and the Millennium Development Goals (MDGs). Also discussed are factors that may contribute to the increasing child survival.

The article discusses the prevalence of child mortality in high-income or developed countries. Topics discussed include five categories of child mortality pattern at various ages, recommendations on how to address child death focusing on key areas such as perinatal causes, natural causes, and preterm birth, effectiveness of providing perinatal interventions to manage preterm birth, and need to intensify government efforts to reduce child mortality.

A letter to the editor is presented in response to the article "Effect of the Newhints home-visits intervention on neonatal mortality rate and care practices in Ghana: A cluster randomised controlled trial," by B. R. Kirkwood and colleagues published in a 2013 issue of "Lancet."

Focuses on the prevention of child and infant mortality in developing countries. Incidence of child and infant mortality in developing nations; International cooperation in the effort to reduce child mortality by two-thirds in accordance with the United Nations (UN) Millennium Development Goals; Successful reduction in child mortality in Indonesia, Sri Lanka, Bangladesh, and other nations over ten years due to improved health care services; Argument that child and infant survival requires increased attention in international relations and policies.

The authors discuss childhood mortality during armed conflicts in Africa. Of particular interest is given to a study by Zachary Wagner and colleagues which expanded the understanding of child mortality during conflicts, suggesting increase risk of childhood mortality from the proximity to conflict. Data and methodological difficulties of measuring child deaths due to conflict are explored.

The article discusses the controversial effects of live vaccines such as oral polio vaccine (OPV), BCG vaccine, and measles vaccine on reducing the infant mortality. The review made by the World Health Organization (WHO) Special Advisory Group of Experts (SAGE) regarding the non-specific effects of vaccines is stated. The suggestion of the WHO that oral polio vaccine (OPV) be replaced by inactivated polio vaccine (IPV) is cited.

The author discusses that more practical solutions are needed for India's health. He says that high infant, child, and maternal mortality rates demonstrate sustained decrease and life expectancy is rising. He adds that some of this is due to hiked national support since 2005, under the coverage of the National Rural Health Mission/National Health Mission (NRHM/NHM).

The article discusses the research conducted by D. You and colleagues on the state of under-5 mortality in 2015, in which they highlighted the success of East Asia, the Pacific and Latin America to achieve the two-thirds reduction aimed by the United Nation's Millennium Development Goals (MDG). Topics discussed include challenges low income nations to address the problem, the state of neonatal mortality and the international process of setting targets.

The article focuses on unifying ministerial responsibilities for child care under the Children Act. Topics discussed include meet the developmental needs of children and integrate paediatric care with public health; dropping several ranks in the European Union league table of child mortality; and rises in neonatal and infant mortality rates for England and Wales in 2018 reported by Office for National Statistics.

Background: Child mortality is almost twice as high in England compared with Sweden. We aimed to establish the extent to which adverse birth characteristics and socioeconomic factors explain this difference.Methods: We developed nationally representative cohorts of singleton livebirths between Jan 1, 2003, and Dec 31, 2012, using the Hospital Episode Statistics in England, and the Swedish Medical Birth Register in Sweden, with longitudinal follow-up from linked hospital admissions and mortality records. We analysed mortality as the outcome, based on deaths from any cause at age 2-27 days, 28-364 days, and 1-4 years. We fitted Cox proportional hazard regression models to estimate the hazard ratios (HRs) for England compared with Sweden in all three age groups. The models were adjusted for birth characteristics (gestational age, birthweight, sex, and congenital anomalies), and for socioeconomic factors (maternal age and socioeconomic status).Findings: The English cohort comprised 3 932 886 births and 11 392 deaths and the Swedish cohort comprised 1 013 360 births and 1927 deaths. The unadjusted HRs for England compared with Sweden were 1·66 (95% CI 1·53-1·81) at 2-27 days, 1·59 (1·47-1·71) at 28-364 days, and 1·27 (1·15-1·40) at 1-4 years. At 2-27 days, 77% of the excess risk of death in England was explained by birth characteristics and a further 3% by socioeconomic factors. At 28-364 days, 68% of the excess risk of death in England was explained by birth characteristics and a further 11% by socioeconomic factors. At 1-4 years, the adjusted HR did not indicate a significant difference between countries.Interpretation: Excess child mortality in England compared with Sweden was largely explained by the unfavourable distribution of birth characteristics in England. Socioeconomic factors contributed to these differences through associations with adverse birth characteristics and increased mortality after 1 month of age. Policies to reduce child mortality in England could have most impact by reducing adverse birth characteristics through improving the health of women before and during pregnancy and reducing socioeconomic disadvantage.Funding: The Farr Institute of Health Informatics Research (through the Medical Research Council, Arthritis Research UK, British Heart Foundation, Cancer Research UK, Chief Scientist Office, Economic and Social Research Council, Engineering and Physical Sciences Research Council, National Institute for Health Research, National Institute for Social Care and Health Research, and the Wellcome Trust). [ABSTRACT FROM AUTHOR]

The article discusses the importance of developing surgical systems for children to minimize the morbidity and mortality of birth defects. Topics include the statistics of birth defects as the fifth leading cause of death in children under five years old worldwide, the global concerted efforts of the Lancet Commission to strengthen surgical systems, and the advantage of the Global Initiative for Children's Surgery (GICS) that has produced the landmark for safe children's surgical care.

The article presents a commentary on the progress and changes in the health care sector in South Africa in 2012. The sector made a number of improvements, including increasing life expectancy and the declining burden of disease related to HIV and tuberculosis. It attributes the improvements in child and infant mortality to rotavirus and pneumococcal vaccination. The challenges facing the health system are identified, including poor performance accountability that affects the quality of care.

The article presents a comment on the study by Yanping Wang and colleagues on the successful reduction of child mortality in China, in which concerns over increasing disparities in child health services, the lack of pediatricians in the country and the need for the Chinese government to focus on child and adolescent health are discussed.

The article discusses the problem on public health and medical care in Myanmar. It tackles the challenge facing the Myanmar Ministry of Health in allocating limited health-care resources effectively, the country's average life expectancy at birth and infant mortality, and the gap in life expectancy at birth between areas with the highest and lowest values.

This editorial comments on a UNICEF report issued in December 2007 that shows progress towards reaching the Millennium Development Goals (MDGs) set to lower mortality in young children. The number of children who die before the age of 5 has dropped to below 10 million a year but many countries have made no progress in stemming child mortality. Pneumonia is the leading cause of death in young children and lack of access to treatment is cited as a reason.

The article presents information on child mortality in Brazil. In this nation, the infant mortality rate decreased from 85.6 to 37.5 per 1000 livebirths during 1980-96. However, this average rate hides great differences between urban and rural regions and between different socioeconomic classes in the same region. Low-income inhabitants of the peripheries of major cities are particularly affected by social exclusion. During 1990-96, governmental and nongovernmental programmes to improve maternal and child health were successful in reducing the postneonatal mortality rate. But the fetal and early neonatal death rate, which has increased from 57% to 63%. To tackle the problem of perinatal deaths, knowledge of the mortality rate and socioeconomic status are not sufficient in the nation. The assessment of the causes of perinatal deaths is more difficult and complex than that of postneonatal and adult deaths due to various factors. In each case there are many factors such as diseases and lesions in the mother, the fetus and the placenta to which the death could be attributed.

This article focuses on the history of infant mortality. One of the most spectacular changes in the last thousand years has been the demographic and health transition in European and North American societies. In this context one must include children's health and illnesses, because the decrease in infant mortality is one of the most perceptible indicators for measuring the progress made in specific geographical areas and also in groups of countries. The medical works corresponding to the Byzantine, Islamic, and Latin Middle Ages and the first three origins of pediatrics in the 15th century offer a wide range of the most frequent pathologies. There was a marked predominance of infectious and contagious illnesses and of nutritional disorders that caused diarrhea and other digestive problems which frequently resulted in death among breastfed infants and in those in their first year. These diseases were in fact the result of important deficiencies in the care of infants, particularly among the lower economic and social groups of the population. From a quantitative point of view there has been a spectacular decrease in infant mortality in the western world in the last two centuries.