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Competing Interests: We declare no competing interests. This work is supported by the Bill & Melinda Gates Foundation (INV-038624 and OPP1172551 to LL and REB). FV acknowledges funding from the Spanish State Research Agency under the Ramón y Cajal programme (RYC2021-033979-I).

Background: Differences in mortality exist between sexes because of biological, genetic, and social factors. Sex differentials are well documented in children younger than 5 years but have not been systematically examined for ages 5-24 years. We aimed to estimate the sex ratio of mortality from birth to age 24 years and reconstruct trends in sex-specific mortality between 1990 and 2021 for 200 countries, major regions, and the world., Methods: We compiled comprehensive databases on the mortality sex ratio (ratio of male to female mortality rates) for individuals aged 0-4 years, 5-14 years, and 15-24 years. The databases contain mortality rates from death registration systems, full birth and sibling histories from surveys, and reports on household deaths in censuses. We modelled the sex ratio of age-specific mortality as a function of the mortality in both sexes using Bayesian hierarchical time-series models. We report the levels and trends of sex ratios and estimate the expected female mortality and excess female mortality rates (the difference between the estimated female mortality and the expected female mortality) to identify countries with outlying sex ratios., Findings: Globally, the mortality sex ratio was 1·13 (ie, boys were more likely to die than girls of the same age) for ages 0-4 years (90% uncertainty interval 1·11 to 1·15) in 2021. This ratio increased with age to 1·16 (1·12 to 1·20) for 5-14 years, reaching 1·65 for 15-24 years (1·52 to 1·75). In all age groups, the global sex ratio of mortality increased between 1990 and 2021, driven by faster declines in female mortality. In 2021, the probability of a newborn male reaching age 25 years was 94·1% (93·7 to 94·4), compared with 95·1% for a newborn female (94·7 to 95·3). We found a disadvantage of females versus males (compared with countries with similar total mortality) in 2021 in five countries for ages 0-4 years (Algeria, Bangladesh, Egypt, India, and Iran), one country (Suriname) for ages 5-14 years, and 13 countries for ages 15-24 years (including Bangladesh and India). We found the reverse pattern (disadvantage of males vs females compared with countries of similar total mortality) in one country in ages 0-4 years (Vietnam) and eight countries in ages 15-24 years (including Brazil and Mexico). Globally, the number of excess female deaths from birth to age 24 years was 86 563 (-6059 to 164 000) in 2021, down from 544 636 (453 982 to 633 265) in 1990., Interpretation: The global sex ratio of mortality for all age groups in the first 25 years of life increased between 1990 and 2021. Targeted interventions should focus on countries with outlying sex ratios of mortality to reduce disparities due to discrimination in health care, nutrition, and violence., Funding: The Bill & Melinda Gates Foundation, US Agency for International Development, and King Abdullah University of Science and Technology., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2023 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: The Sustainable Development Goals (SDGs), set in 2015 by the UN General Assembly, call for all countries to reach an under-5 mortality rate (U5MR) of at least as low as 25 deaths per 1000 livebirths and a neonatal mortality rate (NMR) of at least as low as 12 deaths per 1000 livebirths by 2030. We estimated levels and trends in under-5 mortality for 195 countries from 1990 to 2019, and conducted scenario-based projections of the U5MR and NMR from 2020 to 2030 to assess country progress in, and potential for, reaching SDG targets on child survival and the potential under-5 and neonatal deaths over the next decade., Methods: Levels and trends in under-5 mortality are based on the UN Inter-agency Group for Child Mortality Estimation (UN IGME) database on under-5 mortality, which contains around 18 000 country-year datapoints for 195 countries-nearly 10 000 of those datapoints since 1990. The database includes nationally representative mortality data from vital registration systems, sample registration systems, population censuses, and household surveys. As with previous sets of national UN IGME estimates, a Bayesian B-spline bias-reduction model (B3) that considers the systematic biases associated with the different data source types was fitted to these data to generate estimates of under-5 (age 0-4 years) mortality with uncertainty intervals for 1990-2019 for all countries. Levels and trends in the neonatal mortality rate (0-27 days) are modelled separately as the log ratio of the neonatal mortality rate to the under-5 mortality rate using a Bayesian model. Estimated mortality rates are combined with livebirths data to calculate the number of under-5 and neonatal deaths. To assess the regional and global burden of under-5 deaths in the present decade and progress towards SDG targets, we constructed several scenario-based projections of under-5 mortality from 2020 to 2030 and estimated national, regional, and global under-5 mortality trends up to 2030 for each scenario., Findings: The global U5MR decreased by 59% (90% uncertainty interval [UI] 56-61) from 93·0 (91·7-94·5) deaths per 1000 livebirths in 1990 to 37·7 (36·1-40·8) in 2019, while the annual number of global under-5 deaths declined from 12·5 (12·3-12·7) million in 1990 to 5·2 (5·0-5·6) million in 2019-a 58% (55-60) reduction. The global NMR decreased by 52% (90% UI 48-55) from 36·6 (35·6-37·8) deaths per 1000 livebirths in 1990, to 17·5 (16·6-19·0) in 2019, and the annual number of global neonatal deaths declined from 5·0 (4·9-5·2) million in 1990, to 2·4 (2·3-2·7) million in 2019, a 51% (47-54) reduction. As of 2019, 122 of 195 countries have achieved the SDG U5MR target, and 20 countries are on track to achieve the target by 2030, while 53 will need to accelerate progress to meet the target by 2030. 116 countries have reached the SDG NMR target with 16 on track, leaving 63 at risk of missing the target. If current trends continue, 48·1 million under-5 deaths are projected to occur between 2020 and 2030, almost half of them projected to occur during the neonatal period. If all countries met the SDG target on under-5 mortality, 11 million under-5 deaths could be averted between 2020 and 2030., Interpretation: As a result of effective global health initiatives, millions of child deaths have been prevented since 1990. However, the task of ending all preventable child deaths is not done and millions more deaths could be averted by meeting international targets. Geographical and economic variation demonstrate the possibility of even lower mortality rates for children under age 5 years and point to the regions and countries with highest mortality rates and in greatest need of resources and action., Funding: Bill & Melinda Gates Foundation, US Agency for International Development., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

The 2030 Sustainable Development Goals agenda calls for health data to be disaggregated by age. However, age groupings used to record and report health data vary greatly, hindering the harmonisation, comparability, and usefulness of these data, within and across countries. This variability has become especially evident during the COVID-19 pandemic, when there was an urgent need for rapid cross-country analyses of epidemiological patterns by age to direct public health action, but such analyses were limited by the lack of standard age categories. In this Personal View, we propose a recommended set of age groupings to address this issue. These groupings are informed by age-specific patterns of morbidity, mortality, and health risks, and by opportunities for prevention and disease intervention. We recommend age groupings of 5 years for all health data, except for those younger than 5 years, during which time there are rapid biological and physiological changes that justify a finer disaggregation. Although the focus of this Personal View is on the standardisation of the analysis and display of age groups, we also outline the challenges faced in collecting data on exact age, especially for health facilities and surveillance data. The proposed age disaggregation should facilitate targeted, age-specific policies and actions for health care and disease management., Competing Interests: We declare no competing interests., (© 2021 World Health Organization; licensee Elsevier. This is an Open Access article published under the CC BY-NC-ND 3.0 IGO license.)

Background: The global health community is devoting considerable attention to adolescents and young people, but risk of death in this population is poorly measured. We aimed to reconstruct global, regional, and national mortality trends for youths aged 15-24 years between 1990 and 2019., Methods: In this systematic analysis, we used all publicly available data on mortality in the age group 15-24 years for 195 countries, as compiled by the UN Inter-agency Group for Child Mortality Estimation. We used nationally representative vital registration data, estimated the completeness of death registration, and extracted mortality rates from surveys with sibling histories, household deaths reported in censuses, and sample registration systems. We used a Bayesian B-spline bias-reduction model to generate trends in 10 q 15 , the probability that an adolescent aged 15 years would die before reaching age 25 years. This model treats observations of the 10 q 15 probability as the product of the actual risk of death and an error multiplier that varies depending on the data source. The main outcome that we assessed was the levels of and trends in youth mortality and the global and regional mortality rates from 1990 to 2019., Findings: Globally, the probability of an individual dying between age 15 years and 24 years was 11·2 deaths (90% uncertainty interval [UI] 10·7-12·5) per 1000 youths aged 15 in 2019, which is about 2·5 times less than infant mortality (28·2 deaths [27·2-30·0] by age 1 year per 1000 live births) but is higher than the risk of dying from age 1 to 5 (9·7 deaths [9·1-11·1] per 1000 children aged 1 year). The probability of dying between age 15 years and 24 years declined by 1·4% per year (90% UI 1·1-1·8) between 1990 and 2019, from 17·1 deaths (16·5-18·9) per 1000 in 1990; by contrast with this total decrease of 34% (27-41), under-5 mortality declined by 59% (56-61) in this period. The annual number of deaths declined from 1·7 million (90% UI 1·7-1·9) in 1990 to 1·4 million (1·3-1·5) in 2019. In sub-Saharan Africa, the number of deaths increased by 20·8% from 1990 to 2019. Although 18·3% of the population aged 15-24 years were living in sub-Saharan Africa in 2019, the region accounted for 37·9% (90% UI 34·8-41·9) of all worldwide deaths in youth., Interpretation: It is urgent to accelerate progress in reducing youth mortality. Efforts are particularly needed in sub-Saharan Africa, where the burden of mortality is increasingly concentrated. In the future, a growing number of countries will see youth mortality exceeding under-5 mortality if current trends continue., Funding: UN Children's Fund, Bill & Melinda Gates Foundation, United States Agency for International Development., (Copyright © 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: The UN Sustainable Development Goals (SDGs) call for stratification of social indicators by ethnic groups; however, no recent multicountry analyses on ethnicity and child survival have been done in low-income and middle-income countries (LMICs)., Methods: We used data from Demographic and Health Surveys and Multiple Indicator Cluster Surveys collected between 2010 and 2016, from LMICs that provided birth histories and information on ethnicity or a proxy variable. We calculated neonatal (age 0-27 days), post-neonatal (age 28-364 days), child (age 1-4 years), and under-5 mortality rates (U5MRs) for each ethnic group within each country. We assessed differences in mortality between ethnic groups using a likelihood ratio test, Theil's index, and between-group variance. We used multivariable analyses of U5MR by ethnicity to adjust for household wealth, maternal education, and urban-rural residence., Findings: We included data from 36 LMICs, which included 2 812 381 livebirths among 415 ethnic groups. In 25 countries, significant differences in U5MR by ethnic group were identified (all p<0·05 likelihood ratio test). In these countries, the median mortality ratio between the ethnic groups with the highest and lowest U5MRs was 3·3 (IQR 2·1-5·2; range 1·5-8·5), whereas among the remaining 11 countries, the median U5MR ratio was 1·9 (IQR 1·7-2·5; range 1·4-10·0). Ethnic gaps were wider for child mortality than for neonatal or post-neonatal mortality. In nearly all countries, adjustment for wealth, education, and place of residence did not affect ethnic gaps in mortality, with the exception of Guatemala, India, Laos, and Nigeria. The largest ethnic group did not have the lowest U5MR in any of the countries studied., Interpretation: Significant ethnic disparities in child survival were identified in more than two-thirds of the countries studied. Regular analyses of ethnic disparities are essential for monitoring trends, targeting, and assessing the impact of health interventions. Such analyses will contribute to the effort towards leaving no one behind, which is at the centre of the SDGs., Funding: Bill & Melinda Gates Foundation, UNICEF, Wellcome Trust, Associação Brasileira de Saúde Coletiva., (Copyright © 2020 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: Injuries and violence account for a substantial proportion of the global burden of disease in adolescents, especially among low-income and middle-income countries (LMICs). We aimed to compare the prevalence of unintentional injuries and violence among young adolescents in LMICs., Methods: We did a secondary analysis of data from the Global School-based Student Health Survey (GSHS) for adolescents aged 12-15 years from LMICs collected between 2009 and 2015. Survey data was collected using a standardised questionnaire. We used survey data to calculate the overall prevalence of serious injuries and violence (eg, physical attack, physical fighting) and bullying per country. We did a random-effects meta-analysis to calculate pooled overall and regional estimates. We also did subgroup analyses stratified by sex, age (12-13 years vs 14-15 years), and time period (2009-11 vs 2012-15). Logistic regression models adjusted for sex, weights, stratum, and primary sampling unit were used to analyse the differences in prevalence of serious injuries, violence, and bullying., Findings: We included data from 68 LMICs, including 164 633 young adolescents (77 707 [47·2%] boys; 86 926 [52·8%] girls). The overall prevalence of physical attack, physical fighting, and serious injuries during the past 12 months were 35·6% (95% CI 30·7-40·5), 36·4% (29·9-42·9), and 42·9% (39·0-46·9), respectively. Prevalence varied by WHO region and was higher among boys than girls for injuries (47·8% vs 37·5%, p=0·00094), physical attack (41·0% vs 29·4%, p=0·001), and physical fighting (45·5% vs 26·9%, p<0·0001). Fractures (22·6%, 95% CI 19·1-26·1) and cuts (21·8%, 16·8-26·8) were the most common types of serious injury, and falling was the main cause of these injuries (33·1%, 30·2-35·9). The overall prevalence of bullying at least once in the past 30 days was 34·4% (27·1-41·7), irrespective of age and sex. The most common types of bullying were physical (18·3%, 13·7-23·0), verbal-sexual (13·2%, 10·2-16·2), and racial-ethnic (11·6%, 9·2-14·0)., Interpretation: The prevalence of unintentional injuries and violence remain high among young adolescents in LMICs. These countries should prioritise the development of anti-violence and anti-injury programmes to improve health in their young adolescent populations., Funding: National Natural Science Foundation of China, National Key R&D Program of China, Natural Science Foundation of Zhejiang Province, Sanming Project of Medicine in Shenzhen, K.C. Wong Magna Fund in Ningbo University, and Ningbo Scientific Innovation Team for Environmental Hazardous Factor Control and Prevention., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: Reducing neonatal mortality is an essential part of the third Sustainable Development Goal (SDG), to end preventable child deaths. To achieve this aim will require an understanding of the levels of and trends in neonatal mortality. We therefore aimed to estimate the levels of and trends in neonatal mortality by use of a statistical model that can be used to assess progress in the SDG era. With these estimates of neonatal mortality between 1990 and 2017, we then aimed to assess how different targets for neonatal mortality could affect the burden of neonatal mortality from 2018 to 2030., Methods: In this systematic analysis, we used nationally-representative empirical data related to neonatal mortality, including data from vital registration systems, sample registration systems, and household surveys, to estimate country-specific neonatal mortality rates (NMR; the probability of dying during the first 28 days of life) for all countries between 1990 (or the earliest year of available data) and 2017. For our analysis, we used all publicly available data on neonatal mortality from databases compiled annually by the UN Inter-agency Group for Child Mortality Estimation, which were extracted on or before July 31, 2018, for data relating to the period between 1950 and 2017. All nationally representative data were assessed. We used a Bayesian hierarchical penalised B-splines regression model, which allowed for data from different sources to be weighted differently, to account for variable biases and for the uncertainty in NMR to be assessed. The model simultaneously estimated a global association between NMR and under-5 mortality rate and country-specific and time-specific effects, which enabled us to identify countries with an NMR that was higher or lower than expected. Scenario-based projections were made at the county level by use of current levels of and trends in neonatal mortality and historic or annual rates of reduction that would be required to achieve national targets. The main outcome that we assessed was the levels of and trends in neonatal mortality and the global and regional NMRs from 1990 to 2017., Findings: Between 1990 and 2017, the global NMR decreased by 51% (90% uncertainty interval [UI] 46-54), from 36·6 deaths per 1000 livebirths (35·5-37·8) in 1990, to 18·0 deaths per 1000 livebirths (17·0-19·9) in 2017. The estimated number of neonatal deaths during the same period decreased from 5·0 million (4·9 million-5·2 million) to 2·5 million (2·4 million-2·8 million). Annual NMRs vary widely across the world, but west and central Africa and south Asia had the highest NMRs in 2017. All regions have reported reductions in NMRs since 1990, and most regions accelerated progress in reducing neonatal mortality in 2000-17 versus 1990-2000. Between 2018 and 2030, we project that 27·8 million children will die in their first month of life if each country maintains its current rate of reduction in NMR. If each country achieves the SDG neonatal mortality target of 12 deaths per 1000 livebirths or fewer by 2030, we project 22·7 million cumulative neonatal deaths by 2030. More than 60 countries need to accelerate their progress to reach the neonatal mortality SDG target by 2030., Interpretation: Although substantial progress has been made in reducing neonatal mortality since 1990, increased efforts to improve progress are still needed to achieve the SDG target by 2030. Accelerated improvements are most needed in the regions and countries with high NMR, particularly in sub-Saharan Africa and south Asia., Funding: Bill & Melinda Gates Foundation, United States Agency for International Development., (Copyright © 2019 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: From 1990 to 2016, the mortality of children younger than 5 years decreased by more than half, and there are plentiful data regarding mortality in this age group through which we can track global progress in reducing the under-5 mortality rate. By contrast, little is known on how the mortality risk among older children (5-9 years) and young adolescents (10-14 years) has changed in this time. We aimed to estimate levels and trends in mortality of children aged 5-14 years in 195 countries from 1990 to 2016., Methods: In this analysis of empirical data, we expanded the United Nations Inter-agency Group for Child Mortality Estimation database containing data on children younger than 5 years with 5530 data points regarding children aged 5-14 years. Mortality rates from 1990 to 2016 were obtained from nationally representative birth histories, data on household deaths reported in population censuses, and nationwide systems of civil registration and vital statistics. These data were used in a Bayesian B-spline bias-reduction model to generate smoothed trends with 90% uncertainty intervals, to determine the probability of a child aged 5 years dying before reaching age 15 years., Findings: Globally, the probability of a child dying between the ages 5 years and 15 years was 7·5 deaths (90% uncertainty interval 7·2-8·3) per 1000 children in 2016, which was less than a fifth of the risk of dying between birth and age 5 years, which was 41 deaths (39-44) per 1000 children. The mortality risk in children aged 5-14 years decreased by 51% (46-54) between 1990 and 2016, despite not being specifically targeted by health interventions. The annual number of deaths in this age group decreased from 1·7 million (1·7 million-1·8 million) to 1 million (0·9 million-1·1 million) in 1990-2016. In 1990-2000, mortality rates in children aged 5-14 years decreased faster than among children aged 0-4 years. However, since 2000, mortality rates in children younger than 5 years have decreased faster than mortality rates in children aged 5-14 years. The annual rate of reduction in mortality among children younger than 5 years has been 4·0% (3·6-4·3) since 2000, versus 2·7% (2·3-3·0) in children aged 5-14 years. Older children and young adolescents in sub-Saharan Africa are disproportionately more likely to die than those in other regions; 55% (51-58) of deaths of children of this age occur in sub-Saharan Africa, despite having only 21% of the global population of children aged 5-14 years. In 2016, 98% (98-99) of all deaths of children aged 5-14 years occurred in low-income and middle-income countries, and seven countries alone accounted for more than half of the total number of deaths of these children., Interpretation: Increased efforts are required to accelerate reductions in mortality among older children and to ensure that they benefit from health policies and interventions as much as younger children., Funding: UN Children's Fund, Bill & Melinda Gates Foundation, United States Agency for International Development., (Copyright © 2018 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: The progress to achieve the fourth Millennium Development Goal in reducing mortality rate in children younger than 5 years since 1990 has been remarkable. However, work remains to be done in the Sustainable Development Goal era. Estimates of under-5 mortality rates at the national level can hide disparities within countries. We assessed disparities in under-5 mortality rates by household economic status in low-income and middle-income countries (LMICs)., Method: We estimated country-year-specific under-5 mortality rates by wealth quintile on the basis of household wealth indices for 137 LMICs from 1990 to 2016, using a Bayesian statistical model. We estimated the association between quintile-specific and national-level under-5 mortality rates. We assessed the levels and trends of absolute and relative disparity in under-5 mortality rate between the poorest and richest quintiles, and among all quintiles., Findings: In 2016, for all LMICs (excluding China), the aggregated under-5 mortality rate was 64·6 (90% uncertainty interval [UI] 61·1-70·1) deaths per 1000 livebirths in the poorest households (first quintile), 31·3 (29·5-34·2) deaths per 1000 livebirths in the richest households (fifth quintile), and in between those outcomes for the middle quintiles. Between 1990 and 2016, the largest absolute decline in under-5 mortality rate occurred in the two poorest quintiles: 77·6 (90% UI 71·2-82·6) deaths per 1000 livebirths in the poorest quintile and 77·9 (72·0-82·2) deaths per 1000 livebirths in the second poorest quintile. The difference in under-5 mortality rate between the poorest and richest quintiles decreased significantly by 38·8 (90% UI 32·9-43·8) deaths per 1000 livebirths between 1990 and 2016. The poorest to richest under-5 mortality rate ratio, however, remained similar (2·03 [90% UI 1·94-2·11] in 1990, 1·99 [1·91-2·08] in 2000, and 2·06 [1·92-2·20] in 2016). During 1990-2016, around half of the total under-5 deaths occurred in the poorest two quintiles (48·5% in 1990 and 2000, 49·5% in 2016) and less than a third were in the richest two quintiles (30·4% in 1990, 30·5% in 2000, 29·9% in 2016). For all regions, differences in the under-5 mortality rate between the first and fifth quintiles decreased significantly, ranging from 20·6 (90% UI 15·9-25·1) deaths per 1000 livebirths in eastern Europe and central Asia to 59·5 (48·5-70·4) deaths per 1000 livebirths in south Asia. In 2016, the ratios of under-5 mortality rate in the first quintile to under-5 mortality rate in the fifth quintile were significantly above 2·00 in two regions, with 2·49 (90% UI 2·15-2·87) in east Asia and Pacific (excluding China) and 2·41 (2·05-2·80) in south Asia. Eastern and southern Africa had the smallest ratio in 2016 at 1·62 (90% UI 1·48-1·76). Our model suggested that the expected ratio of under-5 mortality rate in the first quintile to under-5 mortality rate in the fifth quintile increases as national-level under-5 mortality rate decreases., Interpretation: For all LMICs (excluding China) combined, the absolute disparities in under-5 mortality rate between the poorest and richest households have narrowed significantly since 1990, whereas the relative differences have remained stable. To further narrow the rich-and-poor gap in under-5 mortality rate on the relative scale, targeted interventions that focus on the poorest populations are needed., Funding: National University of Singapore, UN Children's Fund, United States Agency for International Development, and the Bill & Melinda Gates Foundation., (Copyright © 2018 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: Previous estimates have highlighted a large global burden of stillbirths, with an absence of reliable data from regions where most stillbirths occur. The Every Newborn Action Plan (ENAP) targets national stillbirth rates (SBRs) of 12 or fewer stillbirths per 1000 births by 2030. We estimate SBRs and numbers for 195 countries, including trends from 2000 to 2015., Methods: We collated SBR data meeting prespecified inclusion criteria from national routine or registration systems, nationally representative surveys, and other data sources identified through a systematic review, web-based searches, and consultation with stillbirth experts. We modelled SBR (≥28 weeks' gestation) for 195 countries with restricted maximum likelihood estimation with country-level random effects. Uncertainty ranges were obtained through a bootstrap approach., Findings: Data from 157 countries (2207 datapoints) met the inclusion criteria, a 90% increase from 2009 estimates. The estimated average global SBR in 2015 was 18·4 per 1000 births, down from 24·7 in 2000 (25·5% reduction). In 2015, an estimated 2·6 million (uncertainty range 2·4-3·0 million) babies were stillborn, giving a 19% decline in numbers since 2000 with the slowest progress in sub-Saharan Africa. 98% of all stillbirths occur in low-income and middle-income countries; 77% in south Asia and sub-Saharan Africa., Interpretation: Progress in reducing the large worldwide stillbirth burden remains slow and insufficient to meet national targets such as for ENAP. Stillbirths are increasingly being counted at a local level, but countries and the global community must further improve the quality and comparability of data, and ensure that this is more clearly linked to accountability processes including the Sustainable Development Goals., Funding: Save the Children's Saving Newborn Lives programme to The London School of Hygiene & Tropical Medicine., (Copyright © 2016 Blencowe et al. Open Access article distributed under the terms of CC BY-NC-ND. Published by Elsevier Ltd.. All rights reserved.)

Background: Under natural circumstances, the sex ratio of male to female mortality up to the age of 5 years is greater than one but sex discrimination can change sex ratios. The estimation of mortality by sex and identification of countries with outlying levels is challenging because of issues with data availability and quality, and because sex ratios might vary naturally based on differences in mortality levels and associated cause of death distributions., Methods: For this systematic analysis, we estimated country-specific mortality sex ratios for infants, children aged 1-4 years, and children under the age of 5 years (under 5s) for all countries from 1990 (or the earliest year of data collection) to 2012 using a Bayesian hierarchical time series model, accounting for various data quality issues and assessing the uncertainty in sex ratios. We simultaneously estimated the global relation between sex ratios and mortality levels and constructed estimates of expected and excess female mortality rates to identify countries with outlying sex ratios., Findings: Global sex ratios in 2012 were 1·13 (90% uncertainty interval 1·12-1·15) for infants, 0·95 (0·93-0·97) for children aged 1-5 years, and 1·08 (1·07-1·09) for under 5s, an increase since 1990 of 0·01 (-0·01 to 0·02) for infants, 0·04 (0·02 to 0·06) for children aged 1-4 years, and 0·02 (0·01 to 0·04) for under 5s. Levels and trends varied across regions and countries. Sex ratios were lowest in southern Asia for 1990 and 2012 for all age groups. Highest sex ratios were seen in developed regions and the Caucasus and central Asia region. Decreasing mortality was associated with increasing sex ratios, except at very low infant mortality, where sex ratios decreased with total mortality. For 2012, we identified 15 countries with outlying under-5 sex ratios, of which ten countries had female mortality higher than expected (Afghanistan, Bahrain, Bangladesh, China, Egypt, India, Iran, Jordan, Nepal, and Pakistan). Although excess female mortality has decreased since 1990 for the vast majority of countries with outlying sex ratios, the ratios of estimated to expected female mortality did not change substantially for most countries, and worsened for India., Interpretation: Important differences exist between boys and girls with respect to survival up to the age of 5 years. Survival chances tend to improve more rapidly for girls compared with boys as total mortality decreases, with a reversal of this trend at very low infant mortality. For many countries, sex ratios follow this pattern but important exceptions exist. An explanation needs to be sought for selected countries with outlying sex ratios and action should be undertaken if sex discrimination is present., Funding: The National University of Singapore and the United Nations Children's Fund (UNICEF)., (Copyright © 2014 Alkema et al. Open Access article distributed under the terms of CC BY-NC-SA. Published by .. All rights reserved.)