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Objective: This study examines trends and puts forward projections of under-5 mortality (U5M) in Bangladesh and identifies the effects of maternal high-risk fertility behaviours and use of healthcare services., Methods: Data from seven waves of the Bangladesh Demographic and Health Survey (1994-2014) were analyzed for trends and projections of U5M and a Chi-square (χ2) test was used to identify if there was any association with maternal high-risk fertility behaviours and use of healthcare services. A multivariate logistic regression model was used to determine the effects of fertility behaviors and healthcare usage on the occurrence of U5M adjusting with confounders., Results: U5M declined from 82.5 to 41.0 per 1000 livebirths during 1994-2014 and is projected to further reduce to 17.6 per 1000 livebirths by 2030. The study identified a noticeable regional variation in U5M with maternal high-risk fertility behaviours including age at birth <18 years (aOR: 1.84, 95% CI: 1.23-2.76) and birth interval <24 months (aOR: 1.56, 95% CI: 1.02-2.37) found to be significant determinants. There was a 39-53% decline in this rate of mortality among women that had used antenatal care services at least four times (aOR, 0.51, 95% CI: 0.27-0.97), delivery care (aOR, 0.47, 95% CI: 0.24-0.95), and had received postnatal care (aOR, 0.61, 95% CI: 0.41-0.91) in their last birth. Cesarean section was found to be associated with a 51% reduction in U5M (aOR, 0.49, 95% CI: 0.29-0.82) compared to its non-use., Conclusion: The Sustainable Development Goals require a U5M rate of 25 per 1000 livebirths to be achieved by 2030. This study suggests that with the current trend of reduction, Bangladesh will achieve this target before the deadline. This study also found that maternal high-risk fertility behaviours and non-use of maternal healthcare services are very prevalent in some regions of Bangladesh and have increased the occurrence of U5M in those areas. This suggests therefore, that policies and programmes designed to reduce the pregnancy rates of women that are at risk and to encourage an increase in the use of maternal healthcare services are needed., Competing Interests: The authors have declared that no competing interests exist.

Background and Objectives: We aimed to calculate the change in under-5 mortality rates (U5MRs) (1990-2016), to assess countries' status regarding Sustainable Development Goal (SDG) 3.2.1 (reducing the U5MR to ≤25 deaths per 1000 live births by 2030), to list the most important causes of death (1990, 2016), and to examine the association between selected SDG indicators and U5MRs using a linear mixed-effects regression., Methods: Ecological study in which we used estimates from the Global Burden of Disease Study 2016 for Central American countries. Results were expressed as U5MRs (deaths per 1000 live births), cause-specific mortality rates (deaths per 100 000 population <5 years of age), and regression coefficients with 95% confidence intervals., Results: U5MRs decreased 65% (1990-2016), and in 2016, all countries but Guatemala had met SDG 3.2.1. The main causes of death were diarrheal diseases (1990; 311.1 per 100 000) and lower respiratory infections (LRIs) (2016; 78.1 per 100 000). When disaggregated by country (2016), congenital birth defects were the most important cause of death in all countries except for in Honduras (neonatal preterm birth) and Guatemala (LRIs). Nutritional status; availability of water, sanitation, and hygiene services; coverage of vaccines; and coverage of contraception were associated with a reduction in U5MRs., Conclusions: Central America has achieved a large reduction in U5MRs. Countries must address both the high mortality caused by LRIs and the rising mortality caused by noncommunicable causes of death through an improvement of SDG indicators that guarantees equitable progress in child survival in the region., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2021 by the American Academy of Pediatrics.)

Background: Declines from high levels of under-5 mortality rate (U5MR) first occurred in Western Europe. Knowledge and technologies gained from early mortality reductions could accelerate the U5MR decline for countries that followed. We explored whether average annual reduction (AAR) in U5MR increased between countries over time in the 20th century., Methods: We used U5MR time series from the Human Mortality Database and United Nations for 110 countries experiencing a decline from 100 to 50 under-5 deaths per 1000 live births during the 20th century., Results: Between 1907 and 1938, the AAR was 2.61 (95% CI 2.09, 3.13) deaths per 1000 live births per year on average and increased by 0.06 (95% CI 0.02, 0.10) deaths for each year that passed before the decline started. Countries going through the decline in 1938-1968 and 1968-1999 showed an AAR of 3.96 and 3.67 (95% CI 3.37, 4.54 and 3.26, 4.07), respectively, with no increase in AAR., Conclusions: Acceleration in U5MR reduction was apparent in today's high-income countries, indicating that greater similarities and capacity may have facilitated the adaptation of mortality reducing knowledge and technologies. Greater emphasis on simple and individual-level interventions or more difficult circumstances may also explain the lack of acceleration in mortality reduction after 1950., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

The Sustainable Development Goals (SDGs) were adopted during the United Nations meeting in 2015 to succeed Millennium Development Goals. Among the health targets, SDG 3.2 is to end preventable deaths of newborns and children under 5 years of age by 2030. These 2 targets aim to reduce neonatal mortality to at least as low as 12 per 1000 live births and under-5 mortality to at least as low as 25 per 1000 live births. Ethiopia is demonstrating a great reduction in child mortality since 2000. In the 2019 child mortality estimation which is nearly 5 years after SDGs adoption, Ethiopia's progress toward reducing the newborns and under-5 mortality lie at 27 and 50.7 per 1000 live births, respectively. The generous financial and technical support from the global partners have helped to achieve such a significant reduction. Nevertheless, the SDG targets for newborns and under-5 mortality reduction are neither attained yet nor met the national plan to achieve by the end of 2019/2020. The partnership dynamics during COVID-19 crisis and the pandemic itself may also be taken as an opportunity to draw lessons and spur efforts to achieve SDG targets. This urges the need to reaffirm a comprehensive partnership and realignment with other interconnected development goals. Therefore, collective efforts with strong partnerships are required to improve the determinants of child health and achieving SDG target reduction until 2030.

Background: Oral rehydration solution (ORS) is a simple intervention that can prevent childhood deaths from severe diarrhea and dehydration. In a previous study, we mapped the use of ORS treatment subnationally and found that ORS coverage increased over time, while the use of home-made alternatives or recommended home fluids (RHF) decreased, in many countries. These patterns were particularly striking within Senegal, Mali, and Sierra Leone. It was unclear, however, whether ORS replaced RHF in these locations or if children were left untreated, and if these patterns were associated with health policy changes., Methods: We used a Bayesian geostatistical model and data from household surveys to map the percentage of children with diarrhea that received (1) any ORS, (2) only RHF, or (3) no oral rehydration treatment between 2000 and 2018. This approach allowed examination of whether RHF was replaced with ORS before and after interventions, policies, and external events that may have impacted healthcare access., Results: We found that RHF was replaced with ORS in most Sierra Leone districts, except those most impacted by the Ebola outbreak. In addition, RHF was replaced in northern but not in southern Mali, and RHF was not replaced anywhere in Senegal. In Senegal, there was no statistical evidence that a national policy promoting ORS use was associated with increases in coverage. In Sierra Leone, ORS coverage increased following a national policy change that abolished health costs for children., Conclusions: Children in parts of Mali and Senegal have been left behind during ORS scale-up. Improved messaging on effective diarrhea treatment and/or increased ORS access such as through reducing treatment costs may be needed to prevent child deaths in these areas.

Competing Interests: As an editor of the journal, KL Hon was not involved in the peer review process. The other authors have no conflicts of interest to disclose.

This paper examines the adverse effects of adolescent childbearing on early childhood mortality in Bangladesh in mother-fixed-effects regressions using individual mortality outcomes of 300,000 children. Children born to young mothers (child brides in Bangladesh) suffer from higher mortality in the first year of life than their siblings born later. The survival chances of children born to mothers aged 15-49 years are 48-81 % higher in infant period as compared to their siblings born in mother's early adolescence (10-14 years). In poor households, these survival effects extend up to the fifth birthday, especially in the poorest households or among uneducated mothers. This evidence points towards a biological channel, probably low birth weight, as the main contributing factor in the first year of life. In the post-infant period, favorable socio-economic factors (wealth, education) seem to compensate the biological disadvantage of adolescent births. Adolescent pregnancies lead annually to estimated 18,700 under-5 deaths in Bangladesh., Competing Interests: Declaration of Competing Interest The author declares that there is no conflict of interest., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Competing Interests: Competing interests: The authors completed the ICMJE Unified Competing Interest form (available upon request from the corresponding author), and declare no conflicts of interest.

Objectives: From 2005 to 2017, the prevalence of mortality in Vietnamese children under five years old showed large regional disparities. In 2017, mortality in the wealthiest region was 12.6‰, whereas the most disadvantaged region it was three times as high, at 36‰. This study aims to identify factors affecting regional disparities of the under-five mortality rate (U5MR) in Vietnam., Methods: We applied Structural Equation Modelling to estimate the degree and the pathway through which undernutrition and socio-economic status (SES) contributed to the under-five mortality disparities., Results: SES is estimated as a common latent factor of three socio-economic measures, that is, education, poverty and income. The direct effect of SES on U5MR is at 2.16 through the underweight pathway, which is 5 times higher than the effect of underweight on U5MR. Through the stunting channel, this direct impact is 1.43, nearly twice as high as the impact of the stunting rate. SES also has an indirect effect on U5MR through these undernutrition pathways. In total, we estimate that an increase in SES index will make the U5MR increase by 2.73‰. Among the three indicators of SES, poverty conveys the strongest signal of a considerable change in SES, thus to a subsequent change in U5MR. Among two types of undernutrition, the effect of stunting on U5MR is dominant, more than 3 times as high as that of underweight., Conclusion: These findings have important implications for socio-economic and health interventions: those that strongly focus on the reduction of regional poverty and stunting rates would be effective in bridging the regional gap in the U5MR in Vietnam., (© 2020 John Wiley & Sons Ltd.)

Background: Current global maternal and child health policies rarely value gender equality or women's rights and are restricted to policies addressing clinical interventions and family planning. Gender equality influences the knowledge, autonomy and utilisation of contraception and healthcare, thereby affecting maternal and child health. This systematic review aims to analyse the concurrent effect of gender equality and contraception on maternal and under-5 child mortality., Methods: A systematic review was conducted to investigate the current evidence. Studies were eligible if three themes-namely, indicators of gender equality (such as female education, labour force participation, gender-based violence), contraception, and maternal or child mortality-were present together in a single article analysing the same sample at the same time., Results: Even though extensive literature on this topic exists, only three studies managed to fit the selection criteria. Findings of two studies indicated an association between intimate partner violence (IPV) and infant mortality, and also reported that women's contraceptive use increased the risk of IPV. The third study found that the mother's secondary education attainment significantly reduced child mortality, while the mother's working status increased the odds of child mortality. The researchers of all included studies specified that contraceptive use significantly reduced the risk of child mortality., Conclusion: Improvement in gender equality and contraception concurrently affect the reduction in child mortality. These findings provide strong support to address the research gaps and to include a gender equality approach towards maternal and child health policies., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Child health has been a health policy priority for more than a century in Chile. Since 2000, new health and intersectoral interventions have been implemented. However, no recent analyses have explored child mortality and equity in Chile, an indispensable input to guide policies towards the achievement of the Sustainable Development Goals, specially, in the context of a deeply unequal country such as many other Latin American countries. Thus, the objectives of this study are to analyze the variations in the risk and the causes of death among Chilean children aged <5 years, to identify the determinants, and to measure inequality of infant mortality from 1990 to 2016., Materials and Methods: An observational study was conducted to analyze the Chilean children's mortality from 1990 to 2016 using under five deaths and live births data from the Vital Statistics System. To describe the variation in the risk of death, a time series analysis was performed for each of the under five mortality rate components. A comparative cause of death analysis was developed for Neonatal and 1-59 months' age groups. The determinants of infant mortality were studied with a descriptive analysis of yearly rates according to mother's and child factors and bivariate logistic regression models at the individual level. Finally, simple and complex measures of inequality at individual level were estimated considering three-year periods., Results: Regarding under 5 mortality: (i) Child survival has improved substantially in the last three decades, with a rapid decline in under five mortality rate between 1990 and 2001, followed by a slower reduction; (ii) early neonatal mortality has become the main component of the under five mortality rate (50.6%); (iii) congenital abnormalities have positioned as the leading cause of death; (iv) an important increase in live births below 1,000 grs. Regarding infant mortality: (i) birth weight and gestational age are the two most relevant risk factors in the neonatal period, while social variables are more significant for post-neonatal mortality and, (ii) the inequality according to mother's education has shown a steady decline, with persistent inequalities in post-neonatal period., Conclusions: The Chilean experience illustrates child health achievements and challenges in a country that transitioned from middle-to high-income in recent decades. Although inequity is one of the main challenges for the country, the health sector by granting universal access was able to reduce disparities. However, closing the gap in post-neonatal mortality is still challenging. To overcome stagnation in neonatal mortality, new and specific strategies must address current priorities, emphasizing the access of vulnerable groups., Competing Interests: No authors have competing interests.

Background: Following a reduction in global child mortality due to communicable diseases, the relative contribution of congenital anomalies to child mortality is increasing. Although infant survival of children born with congenital anomalies has improved for many anomaly types in recent decades, there is less evidence on survival beyond infancy. We aimed to systematically review, summarise, and quantify the existing population-based data on long-term survival of individuals born with specific major congenital anomalies and examine the factors associated with survival., Methods and Findings: Seven electronic databases (Medline, Embase, Scopus, PsycINFO, CINAHL, ProQuest Natural, and Biological Science Collections), reference lists, and citations of the included articles for studies published 1 January 1995 to 30 April 2020 were searched. Screening for eligibility, data extraction, and quality appraisal were performed in duplicate. We included original population-based studies that reported long-term survival (beyond 1 year of life) of children born with a major congenital anomaly with the follow-up starting from birth that were published in the English language as peer-reviewed papers. Studies on congenital heart defects (CHDs) were excluded because of a recent systematic review of population-based studies of CHD survival. Meta-analysis was performed to pool survival estimates, accounting for trends over time. Of 10,888 identified articles, 55 (n = 367,801 live births) met the inclusion criteria and were summarised narratively, 41 studies (n = 54,676) investigating eight congenital anomaly types (spina bifida [n = 7,422], encephalocele [n = 1,562], oesophageal atresia [n = 6,303], biliary atresia [n = 3,877], diaphragmatic hernia [n = 6,176], gastroschisis [n = 4,845], Down syndrome by presence of CHD [n = 22,317], and trisomy 18 [n = 2,174]) were included in the meta-analysis. These studies covered birth years from 1970 to 2015. Survival for children with spina bifida, oesophageal atresia, biliary atresia, diaphragmatic hernia, gastroschisis, and Down syndrome with an associated CHD has significantly improved over time, with the pooled odds ratios (ORs) of surviving per 10-year increase in birth year being OR = 1.34 (95% confidence interval [95% CI] 1.24-1.46), OR = 1.50 (95% CI 1.38-1.62), OR = 1.62 (95% CI 1.28-2.05), OR = 1.57 (95% CI 1.37-1.81), OR = 1.24 (95% CI 1.02-1.5), and OR = 1.99 (95% CI 1.67-2.37), respectively (p < 0.001 for all, except for gastroschisis [p = 0.029]). There was no observed improvement for children with encephalocele (OR = 0.98, 95% CI 0.95-1.01, p = 0.19) and children with biliary atresia surviving with native liver (OR = 0.96, 95% CI 0.88-1.03, p = 0.26). The presence of additional structural anomalies, low birth weight, and earlier year of birth were the most commonly reported predictors of reduced survival for any congenital anomaly type. The main limitation of the meta-analysis was the small number of studies and the small size of the cohorts, which limited the predictive capabilities of the models resulting in wide confidence intervals., Conclusions: This systematic review and meta-analysis summarises estimates of long-term survival associated with major congenital anomalies. We report a significant improvement in survival of children with specific congenital anomalies over the last few decades and predict survival estimates up to 20 years of age for those born in 2020. This information is important for the planning and delivery of specialised medical, social, and education services and for counselling affected families. This trial was registered on the PROSPERO database (CRD42017074675)., Competing Interests: The authors have declared that no competing interests exist.

Background: Despite important progress, the burden of under-5 mortality remains unacceptably high, with an estimated 5.3 million deaths in 2018. Lack of access to health care is a major risk factor for under-5 mortality, and distance to health care facilities has been shown to be associated with less access to care in multiple contexts, but few such studies have used a counterfactual approach to produce causal estimates., Methods: We combined retrospective reports on 18,714 births between 1980 and 1998 from the 2000 Malawi Demographic and Health Survey with a 1998 health facility census that includes the date of construction for each facility, including 335 maternity or maternity/dispensary facilities built in rural areas between 1980 and 1998. We estimated associations between distance to nearest health facility and (i) under-5 mortality, using Cox proportional hazards models, and (ii) maternal health care utilization (antenatal visits prior to delivery, place of delivery, receiving skilled assistance during delivery, and receiving a check-up following delivery), using linear probability models. We also estimated the causal effect of reducing the distance to nearest facility on those outcomes, using a two-way fixed effects approach., Findings: We found that greater distance was associated with higher mortality (hazard ratio 1.007 for one additional kilometer [95%CI 1.001 to 1.014]) and lower health care utilization (for one additional kilometer: 1.2 percentage point (pp) increase in homebirth [95%CI 0.8 to 1.5]; 0.8 pp. decrease in at least three antenatal visits [95% CI - 1.4 to - 0.2]; 1.2 pp. decrease in skilled assistance during delivery [95%CI - 1.6 to - 0.8]). However, we found no effects of a decrease in distance to the nearest health facility on the hazard of death before age 5 years, nor on antenatal visits prior to delivery, place of delivery, or receiving skilled assistance during delivery. We also found that reductions in distance decrease the probability that a woman receives a check-up following delivery (2.4 pp. decrease for a 1 km decrease [95%CI 0.004 to 0.044])., Conclusion: Reducing under-5 mortality and increasing utilization of care in rural Malawi and similar settings may require more than the construction of new health infrastructure. Importantly, the effects estimated here likely depend on the quality of health care, the availability of transportation, the demand for health services, and the underlying causes of mortality, among other factors.

Background: Biannual azithromycin distribution has been shown to reduce child mortality as well as increase antimicrobial resistance. Targeting distributions to vulnerable subgroups such as malnourished children is one approach to reaching those at the highest risk of mortality while limiting selection for resistance. The objective of this analysis was to assess whether the effect of azithromycin on mortality differs by nutritional status., Methods and Findings: A large simple trial randomized communities in Niger to receive biannual distributions of azithromycin or placebo to children 1-59 months old over a 2-year timeframe. In exploratory subgroup analyses, the effect of azithromycin distribution on child mortality was assessed for underweight subgroups using weight-for-age Z-score (WAZ) thresholds of -2 and -3. Modification of the effect of azithromycin on mortality by underweight status was examined on the additive and multiplicative scale. Between December 2014 and August 2017, 27,222 children 1-11 months of age from 593 communities had weight measured at their first study visit. Overall, the average age among included children was 4.7 months (interquartile range [IQR] 3-6), 49.5% were female, 23% had a WAZ < -2, and 10% had a WAZ < -3. This analysis included 523 deaths in communities assigned to azithromycin and 661 deaths in communities assigned to placebo. The mortality rate was lower in communities assigned to azithromycin than placebo overall, with larger reductions among children with lower WAZ: -12.6 deaths per 1,000 person-years (95% CI -18.5 to -6.9, P < 0.001) overall, -17.0 (95% CI -28.0 to -7.0, P = 0.001) among children with WAZ < -2, and -25.6 (95% CI -42.6 to -9.6, P = 0.003) among children with WAZ < -3. No statistically significant evidence of effect modification was demonstrated by WAZ subgroup on either the additive or multiplicative scale (WAZ < -2, additive: 95% CI -6.4 to 16.8, P = 0.34; WAZ < -2, multiplicative: 95% CI 0.8 to 1.4, P = 0.50, WAZ < -3, additive: 95% CI -2.2 to 31.1, P = 0.14; WAZ < -3, multiplicative: 95% CI 0.9 to 1.7, P = 0.26). The estimated number of deaths averted with azithromycin was 388 (95% CI 214 to 574) overall, 116 (95% CI 48 to 192) among children with WAZ < -2, and 76 (95% CI 27 to 127) among children with WAZ < -3. Limitations include the availability of a single weight measurement on only the youngest children and the lack of power to detect small effect sizes with this rare outcome. Despite the trial's large size, formal tests for effect modification did not reach statistical significance at the 95% confidence level., Conclusions: Although mortality rates were higher in the underweight subgroups, this study was unable to demonstrate that nutritional status modified the effect of biannual azithromycin distribution on mortality. Even if the effect were greater among underweight children, a nontargeted intervention would result in the greatest absolute number of deaths averted., Trial Registration: The MORDOR trial is registered at clinicaltrials.gov NCT02047981., Competing Interests: The authors have declared that no competing interests exist.

A conclusion of the European Fertility Project in 1986 was that pretransition populations mostly displayed natural fertility, where parity-dependent birth control was absent. This conclusion has recently been challenged for England by new empirical results and has also been widely rejected by theorists of long-run economic growth, where pre-industrial fertility control is integral to most models. In this study, we use the accident of twin births to show that for three Western European-derived pre-industrial populations-namely, England (1730-1879), France (1670-1788), and Québec (1621-1835)-we find no evidence for parity-dependent control of marital fertility. If a twin was born in any of these populations, family size increased by 1 compared with families with a singleton birth at the same parity and mother age, with no reduction of subsequent fertility. Numbers of children surviving to age 14 also increased. Twin births also show no differential effect on fertility when they occurred at high parities; this finding is in contrast to populations where fertility is known to have been controlled by at least some families, such as in England, 1900-1949, where a twin birth increased average births per family by significantly less than 1.

Background: Four Andean countries of Bolivia, Colombia, Ecuador, and Peru introduced national health-focused conditional cash transfer (CCT) programs in the 2000s. This study probes whether policymakers in these countries targeted CCT programs to subregions with the highest prevalence of ill-health or those with the lowest socioeconomic status (SES) to evaluate the equity of geographic targeting and means-testing, as well as the potential role of normative frames, bounded rationality, and clientelism as explanatory mechanisms for inequities in social spending., Methods: The distribution of vaccination coverage, underweight, stunting, and child deaths is established both within and between subnational regions and SES quintiles from 1998 to 2012 using every available nationally representative household survey. The equity of CCT program targeting and strength of association with subregional SES and health outcomes are measured using generalized entropy index decomposition and meta-regression. Finally, simple predictive models for CCT targeting are created using lagged subregional SES, health outcomes, and concentration indices., Results: Bolivia and Peru both effectively targeted at-risk subregions, but subregions in Peru with no CCT program coverage result in higher mistargeting rates for the country as a whole. Only Bolivia failed to attain CCT coverage concentration indices that are at least as large as the health inequalities they are targeting. Despite this insufficient progressivity, Bolivia has the most efficient subregional targeting, while the lowest rates of mistargeting for child deaths are found in Colombia and Ecuador. Finally, the simple predictive model performs as well or better than observed CCT coverage distribution for every country, year, and outcome., Conclusions: Both Peru and Ecuador have targeted programs to their poorest populations effectively, demonstrating that this is possible with both universal and geographic targeting. No clear evidence of clientelism was found, while the dominant normative frame underlying CCT program targeting decisions appears to be the relative SES of subregions, rather than absolute SES, prevalence of health outcomes, or health inequalities. To reduce the inequitable impacts of bounded rationality, policymakers can use simple predictive models to target CCT coverage effectively and without leaving behind the most vulnerable populations that happen to live in more affluent subregions.

Background: This study analyzed the trends and seasonality in mortality among children aged 0-14 years in Guangzhou, China during 2008-2018. Understanding the epidemiology of this public health problem can guide policy development for children mortality prevention., Methods: A population-based epidemiological retrospective study was conducted. Seven thousand two hundred sixty-five individual data of children mortality were obtained from the Guangzhou Center for Disease Control and Prevention (CDC). The Poisson regression was used to quantify the annual average reduction rate and the difference in mortality rate between sex and age groups. Incidence ratio with 95% confidence interval (CI) was estimated to determine the temperaol variations in mortality by month, season, school term, day of the week and between holidays and other days., Results: Between 2008 and 2018, the children mortality rate in Guangzhou decreased from 54.0 to 34.3 per 100,000 children, with an annual reduction rate of 4.6% (95% CI: 1.1%-8.1%), especially the under-5 mortality rate decreased by 8.3% (95% CI: 4.8%-11.6%) per year. Decline trends varied by causes of death, even with an upward trend for the mortality of asphyxia and neurological diseases. The risk of death among males children was 1.33 times (95% CI: 1.20-1.47) of that of females. The distribution of causes of death differed by age group. Maternal and perinatal, congenital and pneumonia were the top three causes of death in infants and cancer accounted for 17% of deaths in children aged 1-14 years. Moreover, the injury-related mortality showed significant temporal variations with higher risk during the weekend. And there was a summer peak for drowning and a winter peak for asphyxia., Conclusions: Guangzhou has made considerable progress in reducing mortality over the last decade. The findings of characteristics of children mortality would provide important information for the development and implementation of integrated interventions targeted specific age groups and causes of death.

Reducing the mortality of children under-5 (U5) is an essential part of the Sustainable Development Goal (SDG). Although Bangladesh has made progress in reducing child mortality, there remain inequalities among different sociodemographic groups. Education is one particular key factor with a multidimensional impact on child health and survival. This study assessed the association between parental education and U5 mortality using repeated cross-sectional Bangladesh Demographic and Health Survey data. The risk of child death was substantially low among educated parents. Children of secondary or higher educated mother and father were about 30% (hazard ratio [HR] = 0.697, 95% confidence interval [CI] 0.596 to 0.815, p < .001) and 26% (HR = 0.738, 95% CI 0.635 to 0.858, p < .001), respectively, less likely to die early. Children from wealthier households and born to mothers with long birth spacings were less likely to face an early death. The study findings emphasize on imparting education to parents as an intervention strategy to continue the reduction of child mortality rate in Bangladesh, which could be a policy direction toward achieving the SDGs.

Despite demographers' long-standing preoccupation with the effects of child mortality on women's fertility desires, scholars continue to know little about the consequences of other pervasive mortality exposures. We use nationally representative data from the high-mortality context of Peru to examine whether the desire to have a(nother) child varies as a function of sibling loss and to assess heterogeneity in this association by women's current number of children and a range of conditions related to siblings' deaths. Women who have experienced sibling bereavement and have two or more children report higher odds of desiring another child. These effects are not contingent on the age or sex of the deceased sibling but are only significant if the sibling died during the respondent's lifetime (not before). These findings highlight the theoretical and empirical import of investigating the relationship between fertility desires and a wider range of familial mortality exposures beyond own child mortality.

Previous studies have documented varying fertility responses to childhood mortality and to the sex composition of the surviving offspring during the demographic transition. We contribute to this literature by applying a mixture cure model to reproductive histories of Estonian women born 1850-99. This model, unlike standard event history models, is capable of separating the effect of the covariates on the propensity of having another birth from their effect on its timing. Child fatalities, not having sons, and to a smaller extent, not having daughters, increased the propensity to have another child and decreased the interval to it. The response was stronger among later cohorts, but only with respect to parity progression. By contrast, the accelerated childbearing response diminished over time. Our findings suggest that behavioural responses in the quantum and tempo of childbearing can occur relatively independently.

Background: Injuries are a major cause of disease, long-term disability and death. Injury-related damage accounts for 12% of the burden of disease worldwide. Recently, significant improvements in child health have been achieved in the Islamic Republic of Iran: under-5 mortality was reduced substantially from 1990 to 2013. Nevertheless, injury is still a significant cause of mortality in this age group., Aims: Because of their vulnerability and the high rates of injury-related mortality among children under-5, this study aimed at investigating explanatory social variables of injury-related mortality., Methods: The study was conducted using the Commission on Social Determinants of Health conceptual framework among children aged under-5 years in Isfahan Province. Using the national child mortality surveillance system 1433 under- 5 mortalities during 2010-2015 were secondary analysed., Results: We found 403 (28%) cases were related to injury. Most of the deaths occurred in 706 infants (49.2%), among boys (54.8%) and urban residents (78.9%). Multivariate logistic regression showed that mothers' low education level, age 1-5 years', living in a supportive centre and having financial problems increased the odds of under-5 mortality caused by injury (odds ratio > 1, P-value ≤ 0.05)., Conclusion: Considering the importance and impacts of social factors on injury-related mortality among children, health policy-makers should initially consider the social determinants of health approach in child health programmes to inform interventions aimed at reducing injury-related mortality., (Copyright © World Health Organization (WHO) 2020. Open Access. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https://creativecommons.org/licenses/by-nc-sa/3.0/igo).)

Background: Verbal autopsy is the main method used in countries with weak civil registration systems for estimating community causes of neonatal and 1-59-month-old deaths. However, validation studies of verbal autopsy methods are limited and assessment has been dependent on hospital-based studies, with uncertain implications for its validity in community settings. If the distribution of community deaths by cause was similar to that of facility deaths, or could be adjusted according to related demographic factors, then the causes of facility deaths could be used to estimate population causes., Methods: Causes of neonatal and 1-59-month-old deaths from verbal/social autopsy (VASA) surveys in four African countries were estimated using expert algorithms (EAVA) and physician coding (PCVA). Differences between facility and community deaths in individual causes and cause distributions were examined using chi-square and cause-specific mortality fractions (CSMF) accuracy, respectively. Multinomial logistic regression and random forest models including factors from the VASA studies that are commonly available in Demographic and Health Surveys were built to predict population causes from facility deaths., Results: Levels of facility and community deaths in the four countries differed for one to four of 10 EAVA or PCVA neonatal causes and zero to three of 12 child causes. CSMF accuracy for facility compared to community deaths in the four countries ranged from 0.74 to 0.87 for neonates and 0.85 to 0.95 for 1-59-month-olds. Crude CSMF accuracy in the prediction models averaged 0.86 to 0.88 for neonates and 0.93 for 1-59-month-olds. Adjusted random forest prediction models increased average CSMF accuracy for neonates to, at most, 0.90, based on small increases in all countries., Conclusions: There were few differences in facility and community causes of neonatal and 1-59-month-old deaths in the four countries, and it was possible to project the population CSMF from facility deaths with accuracy greater than the validity of verbal autopsy diagnoses. Confirmation of these findings in additional settings would warrant research into how medical causes of deaths in a representative sample of health facilities can be utilized to estimate the population causes of child death.

Child death overview panels (CDOPs) were set up in the United Kingdom following the confidential enquiry into maternal and child health. Their scope is to identify learning points and modifiable factors that focus on improving services and prevent further deaths. In the light of UK national review and subsequent legislative changes to local safeguarding arrangements, we wanted to share the lessons learnt from our local network study during this time of transition. At times of system change, organizational memory can be eroded, which results in lost opportunities to further strengthen multi-agency working in practice. Overall, our local study highlighted key learning points which could be of use in emergent safeguarding partnerships. Professionals need to continue to actively pursue and create opportunities to collect and collate comprehensive data and promote collaborative multi-agency arrangements. Panels need to be responsive to all partners involved in the safeguarding process, which includes parents. A level of reciprocity needs to be nurtured for safeguarding panel members and acute care providers to work in ways which promote learning, consider emotional support systems and explore ways to define and mobilize knowledge that can inform the safeguarding process and prevent future avoidable child deaths.

Background: There has been a global rise in interest and efforts to improve under-five mortality rates, especially in low- and middle-income countries. Ghana has made some progress in improving this outcome; however, the extent of such progress and its equity implications remains understudied., Methods: This study used a joinpoint regression analysis to assess the significance of changes in trends of under-five mortality rates in Ghana between 1988 and 2017 using data from seven rounds of the Ghana Demographic and Health Survey. Annual percentage change (APC) was estimated. The APCs of different dimensions of equity (residence, administrative region, maternal education and wealth quintile) were compared by coincidence test - to determine similarity in joinpoint regression functions via 10 000 Monte Carlo resampling., Results: There has been progress in reduction of under-five mortality in Ghana between 1988 and 2017 with an annual percentage change of -3.49%. Disaggregation of the trends showed that the most rapid improvement in under-five mortality rates occurred in the Upper East Region (APC = -5.0%). The closing of under-five mortality equity gaps in the study period has been uneven in the country. The gap between rural and urban rates has closed the most, followed by regional gaps (between Upper East and Ashanti Region), while the most persistent gaps remain in maternal education and wealth quintile., Conclusion: The findings suggest that programmatic interventions have been more successful in reducing geographic (rural-urban and by administrative region) than non-geographic (maternal education and wealth quintile) inequities in under-five mortality in Ghana. To accelerate reduction and bridge the inequities in under-five mortality, Ghana may need to pursue more social policies aimed at redistribution., (© 2020 John Wiley & Sons Ltd.)

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., (© 2020 World Health Organization; licensee Elsevier. This is an Open Access article published under the CC BY 3.0 IGO license which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. In any use of this article, there should be no suggestion that WHO endorses any specific organisation, products, or services. The use of the WHO logo is not permitted. This notice should be preserved along with the article's original URL.)

Background: Child mortality has been reduced by more than 50 % over the past 30 years. A range of secular economic and social developments have been considered to explain this phenomenon. In this paper, we examine the association between ratification of the Convention on the Rights of the Child (CRC), which was specifically put in place to ensure the well-being of children, and declines in child mortality., Methods: Data come from three sources: the United Nations Treaty Series Database, the World Bank World Development Indicators database and, the Polity IV database. Because CRC was widely ratified, leaving few control cases, we used interrupted times series analyses, which uses the trend in the health outcome before policy exposure to mathematically determine what the trend in the health outcome would have been after the policy exposure, if it had continued 'as is' - meaning, if the policy exposure had not occurred., Results: CRC ratification was associated with declining child mortality. CRC ratification was associated with a significant change in shorter-term child mortality trends in all groups except high-income, non-democratic countries and low-imcome democratic countries. CRC ratification was associated with long-term child mortality trends in all groups except middle-income, non-democratic countries., Conclusions: Child mortality rates would likely have declined even in the absence of CRC ratification, but CRC is associated with a larger decline. Our findings provide a way to assess the effects of widely-held societal norms on health and demonstrate the moderating effects of democracy and income level.

Background: A growing body of evidence suggests that early life health and developmental outcomes can be improved through parental support programs. The objective of this project was to test the feasibility, impact, and relative cost-effectiveness of an adapted "Reach Up and Learn" program delivered through home-visiting programs as well as through center-based parenting groups on child health and development in the municipality of Boa Vista, Brazil., Methods: A randomized, stepped-wedge design was used to roll out and evaluate the two parenting platforms in Boa Vista municipality. A total of 39 neighborhoods with a high Neighborhood Vulnerability Index were selected for the study. For the first phase of the program, nine neighborhoods were randomly selected for home visits, and two were randomly selected for the center-based parenting groups. In the second phase of the program, 10 neighborhoods were added to the home-visiting program, and eight were added to the center-based program. In the final phase of the program, the remaining 10 control areas will also be assigned to treatment. Study eligibility will be assessed through a baseline survey completed by all pregnant women in the 39 study areas. Pregnant women will be eligible to participate in the study if they are either classified as poor, were under age 20 years when they became pregnant, or if they indicate to have been exposed to domestic or sexual violence. To assess program impact, an endline survey will be conducted when children reach age 2 years. The primary study outcome is child development at age 2 years as measured by the PRIDI instrument. Secondary outcome will be infant mortality, which will be assessed linking municipal vital registration systems to the program rollout., Discussion: This trial will assess the feasibility and impact of parenting programs rolled out at medium scale. The results from the trial should create evidence urgently needed for guiding Brazil's national Criança Feliz program as well as similar efforts in other countries., Trial Registration: ClinicalTrials.gov, ID: NCT03386747. Registered on 13 December 2017. All items of the World Health Organization Trial Registration Data Set are available in this record.

Background: Since 2009, the Chinese government has been reforming the healthcare system and has committed to reinforcing increased use of primary care. To date, however, the Chinese healthcare system is still heavily reliant on hospital-based specialty care. Studies consistently show an association between primary care and improved health outcomes, and the same association is also found among the disadvantaged population. Due to the "hukou" system, interprovincial migrants in the urban districts are put in a weak position and become the disadvantaged. Therefore, the aim of this study is to investigate whether greater supply and utilization of primary care was associated with reduced child mortality among the entire population and the interprovincial migrants in urban districts of Guangdong province, China., Methods: An ecological study was conducted using a 3-year panel data with repeated measurements within urban districts in Guangdong province from 2014 to 2016, with 178 observations in total. Multilevel linear mixed effects models were applied to explore the associations., Results: Higher visit proportion to primary care was associated with reductions in the infant mortality rate and the under-five mortality rate in both the entire population and the interprovincial migrants (p < 0.05) in the full models. The association between visit proportion to primary care and reduced neonatal mortality rate was significant among the entire population (p < 0.05) while it was insignificant among the interprovincial migrants (p > 0.05)., Conclusions: Our ecological study based in urban districts of Guangdong province found consistent associations between higher visit proportion to primary care and improvements in child health among the entire population and the interprovincial migrants, suggesting that China should continue to strengthen and develop the primary care system. The findings from China adds to the previously reported evidence on the association between primary care and improved health, especially that of the disadvantaged.

Context: Information regarding the impact of parental multiple endocrine neoplasia type 1 (MEN 1) on neonatal outcomes is limited to case reports., Objective: To determine the impact of parental MEN 1 on neonatal outcomes., Methods: Retrospective cohort analysis of the Tasman 1 MEN 1 kindred stratified by whether birth occurred before ("historical cohort") or after ("contemporary cohort") prospective screening commenced. The historical cohort included kindred members born between 1825 and 1984 (n = 341 children with a MEN 1 positive (MEN 1+) parent and n = 314 children with MEN 1 negative (MEN 1-) parents). The contemporary cohort included neonates (n = 52) of MEN 1+ women (n = 21) managed at a tertiary referral hospital between 1985 and 2018., Results: Historical cohort: compared with MEN 1- parents, children of MEN 1+ parents were more likely to die postpartum (HR 4.6, P = .046 at 6 months of age). Excess mortality at 15 years of age was observed for children of MEN 1+ mothers (HR 8.50, P = .002) and fathers (HR 3.82, P = .03). Contemporary cohort: neonates of MEN 1+ mothers were more likely to have low birth weight (28.9% vs 6.7%, P = .01), be admitted to a higher care nursery (40.4% vs 17%, P = .02), and require a longer median postnatal stay (5 vs 4 days, P = .009) than the Australian average. Isolated antenatal hypercalcemia did not significantly alter neonatal outcomes., Conclusion: Children with a MEN 1+ parent are disproportionately vulnerable postpartum. Neonates of MEN 1+ mothers remain vulnerable despite contemporary care. The excess risk was not fully explained by maternal MEN 1 or antenatal hypercalcemia., (© Endocrine Society 2019. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Education and health are both constituents of human capital that enable people to earn higher wages and enhance people's capabilities. Human capabilities may lead to fulfilling lives by enabling people to achieve a valuable combination of human functionings-i.e., what people are able to do or be as a result of their capabilities. A better understanding of how these different human capabilities are produced together could point to opportunities to help jointly reduce the wide disparities in health and education across populations., Methods and Findings: We use nationally and regionally representative individual-level data from Demographic and Health Surveys (DHS) for 55 low- and middle-income countries (LMICs) to examine patterns in human capabilities at the national and regional levels, between 2000 and 2017 (N = 1,657,194 children under age 5). We graphically analyze human capabilities, separately for each country, and propose a novel child-based Human Development Index (HDI) based on under-five survival, maternal educational attainment, and measures of a child's household wealth. We normalize the range of each component using data on the minimum and maximum values across countries (for national comparisons) or first-level administrative units within countries (for subnational comparisons). The scores that can be generated by the child-based HDI range from 0 to 1. We find considerable heterogeneity in child health across countries as well as within countries. At the national level, the child-based HDI ranged from 0.140 in Niger (with mean across first-level administrative units = 0.277 and standard deviation [SD] 0.114) to 0.755 in Albania (with mean across first-level administrative units = 0.603 and SD 0.089). There are improvements over time overall between the 2000s and 2010s, although this is not the case for all countries included in our study. In Cambodia, Malawi, and Nigeria, for instance, under-five survival improved over time at most levels of maternal education and wealth. In contrast, in the Philippines, we found relatively few changes in under-five survival across the development spectrum and over time. In these countries, the persistent location of geographical areas of poor child health across both the development spectrum and time may indicate within-country poverty traps. Limitations of our study include its descriptive nature, lack of information beyond first- and second-level administrative units, and limited generalizability beyond the countries analyzed., Conclusions: This study maps patterns and trends in human capabilities and is among the first, to our knowledge, to introduce a child-based HDI at the national and subnational level. Areas of chronic deprivation may indicate within-country poverty traps and require alternative policy approaches to improving child health in low-resource settings., Competing Interests: The authors have declared that no competing interests exist.

It is uncertain whether Latin America and Caribbean (LAC) countries are approaching a single mortality regime. Over the last three decades, LAC has experienced major public health interventions and the highest number of homicides in the world. However, these interventions and homicide rates are not evenly shared across countries. This study documents trends in life expectancy and lifespan variability for 20 LAC countries, 2000-14. By extending a previous method, we decompose differences in lifespan variability between LAC and a developed world benchmark into cause-specific effects. For both sexes, dispersion of amenable diseases through the age span makes the largest contribution to the gap between LAC and the benchmark. Additionally, for males, the concentration of homicides, accidents, and suicides in mid-life further impedes mortality convergence. Great disparity exists in the region: while some countries are rapidly approaching the developed regime, others remain far behind and suffer a clear disadvantage in population health.

Purpose: Health improves the proficiency and output generated by individuals. It also raises physical as well as mental abilities, which are required for the growth and advancement of any economy. Many infant diseases have been recognised via contemporary technology in a bid to tackle these diseases. However, children within the African continent (Including Nigeria) die en masse from diseases. This has made the government of Nigeria allocate sizeable part of the nation's budget to healthcare system. The allocation to health is, however, yet to translate to improved health condition for Nigerians. It does not measure up to the World Health Organization's (WHO) standards for apportioning budget to the health sector. This study also analyses empirically the impact of healthcare expenses on the mortality level of infants as well as Nigeria's neonatal mortality level., Design/methodology/approach: The paper focuses on Nigeria. Vector auto regression model techniques, unit root tests and cointegration test were carried out using time series date for the period between 1986 and 2016., Findings: The outcome has revealed that expenditure on healthcare possesses a negative correlation with the mortality of infants and neonates. The study discovers that if the Nigerian government raises and maintains health expenditure specifically on activities focused on minimising infant mortality, it will translate to reduction in infant mortality in Nigeria., Originality/value: This paper has contributed exhaustively to solution to poor expenditure on healthcare, especially child mortality, in Nigeria., (© Emerald Publishing Limited.)

Background: Child mortality rates are considered to be one of the key indicators of child health., Aims: The main objective of this research was to calculate child mortality rates (CMRs) indirectly, using census data, and to investigate using spatial pattern analysis the presence of any clustering patterns among provincial regions., Methods: The Trussell version of the Brass method and Coale-Demeny West model were used to estimate CMRs and life expectancy (LE) at birth. The analyses were performed using the QFive program of MORTPAK 4 software. For cluster analysis, local and global Moran's I indexes were measured., Results: Infant mortality rate, under-5 mortality rate, 1-4 mortality rate and LE at birth were estimated as 21.9, 26, 4.1 (deaths per 1000 live births) and 72.1 years, respectively. Global Moran's I index was calculated as 0.09, 0.09, 0.08 and 0.12, respectively., Conclusion: Special attention must be paid in provinces with high clusters regarding the evaluation of public health programmes, and the cause of failure of these programmes in reduction of childhood mortality indices., (Copyright © World Health Organization (WHO) 2020. Open Access. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https://creativecommons.org/licenses/by-nc-sa/3.0/igo).)

Introduction: Measles is a highly infectious vaccine-preventable viral disease that mostly affects children less than five years old. Jigawa located in the north-west zone has the highest burden of measles in Nigeria. We reviewed Jigawa State measles surveillance data to identify measles trend and factors associated with mortality., Methods: We conducted a secondary data analysis of measles specific integrated disease surveillance and response data for Jigawa State from January 2013 to December 2017. We extracted relevant variables and analyzed data using descriptive statistics and logistic regression model (α = 0.05). We estimated seasonal variation using an additive time series model., Results: A total of 6,214 cases were recorded with 1038 (16.7%) confirmed by laboratory investigation. Only 1,185 (19.7%) had at least one dose of measles vaccine. Age specific attack and fatality rates were highest among children under the age of five years (503/100,000 and 1.8% respectively). The trend showed a decrease in number of cases across all the years. Seasonal variation existed with cases peaking in the first quarter. The likelihood of mortality associated with measles was higher among cases who had no vaccination (AOR = 4.7, 95% CI: 2.9-7.5) than those who had at least one dose of measles vaccine., Conclusion: There was a decrease in the trend of measles cases, however, the vaccination coverage was very low in Jigawa State. Receiving at least one dose of measles vaccine reduces mortality among the cases. Strengthening routine immunization will reduce number of cases and mortality associated with the disease., Competing Interests: The authors declare no competing interests., (© Aisha Sani Faruk et al.)

Introduction: The third Sustainable Development Goal, focused on health, includes two targets related to the reduction in maternal, newborn and under-five childhood mortality. We found it imperative to examine the equity and coverage of reproductive, maternal, newborn and child health (RMNCH) interventions from 2001 to 2016 in Nepal; and the death aversion that will take place during the SDG period., Methods: We used the datasets from the Nepal Demographic Health Surveys (NDHS) 2001, 2006, 2011 and 2016. We calculated the coverage and equity for RMNCH interventions and the composite coverage index (CCI). Based on the Annualized Rate of Change (ARC) in the coverage for selected RMNCH indicators, we projected the trend for the RMNCH interventions by 2030. We used the Lives Saved Tools (LiST) tool to estimate the maternal, newborn, under-five childhood deaths and stillbirths averted. We categorised the interventions into four different patterns based on coverage and inequity gap., Results: Between 2001 and 2016, a significant improvement is seen in the overall RMNCH intervention coverage-CCI increasing from 46 to 75%. The ARC was highest for skilled attendance at birth (11.7%) followed by care seeking for pneumonia (8.2%) between the same period. In 2016, the highest inequity existed for utilization of the skilled birth attendance services (51%), followed by antenatal care (18%). The inequity gap for basic immunization services reduced significantly from 27.4% in 2001 to 5% in 2016. If the current ARC continues, then an additional 3783 maternal deaths, 36,443 neonatal deaths, 66,883 under-five childhood deaths and 24,024 stillbirths is expected to be averted by the year 2030., Conclusion: Nepal has experienced an improvement in the coverage and equity in RMNCH interventions. Reducing inequities will improve coverage for skilled birth attendants and antenatal care. The current annual rate of change in RMNCH coverage will further reduce the maternal, neonatal, under-five childhood deaths and stillbirths.

In China, parents who have lost their only child and remained childless are labelled Shidu () parents. Previous research suggests high levels of psychological distress in this population, yet little is known regarding the prevalence of prolonged grief disorder (PGD) based on the new ICD-11 formulation. The present study examined prevalence rates and associated factors of prolonged grief disorder in this population. 1030 Chinese Shidu parents (381 male, 643 female) who were recruited through convenient sampling completed questionnaires assessing grief severity. Multiple linear regression models were used to examine socio-demographic, loss-related and self-reported number of chronic physical conditions associated with PGD symptoms. Results showed prevalence rate was 35.5% based on the ICD-11 PGD criteria, which was almost twice as that of Prigerson et al. (2009) criteria. Younger age of parents, being a mother, living in a rural place, lower monthly income per capital, shorter time since loss and more comorbid chronic physical conditions were related to severer PGD symptoms. The present findings revealed high rates of PGD experienced by Chinese Shidu parents and identified key risk factors which can be used for future prevention or intervention designs in this population., Competing Interests: Declaration of Competing Interest The authors declare no conflict of interests. Andreas Maercker was the chair of the work group on disorders specifically associated with stress in ICD-11 development at WHO. The views expressed reflect the opinions of the authors and not necessarily the Working Group and the content of this article does not represent WHO policy., (Copyright © 2020. Published by Elsevier B.V.)

Objective: To describe and analyze data on self-injurious behavior (SIB) and related mortality in children under 10 years old in Brazil., Methods: A descriptive study was performed using secondary public health care data extracted from the Hospital Information System (Sistema de Informações Hospitalares, SIH) and Mortality Information System (Sistema de Informações sobre Mortalidade, SIM) in Brazil. The databases are available for online access at http://datasus.saude.gov.br/., Results: In Brazil, according to SIH data, 11,312 hospitalizations of patients under 10 years of age were recorded from 1998 to 2018 as resulting from SIB (ICD-10 X60-X84 codes). Of these, 65 resulted in death. According to the SIM, from 1996 to 2016, 91 deaths related to SIB were recorded, 81 (89%) in children aged 5 to 9 years, nine (9.9%) in children aged 1 to 4 years, and one (1.1%) in a child below 1 year of age., Conclusion: These results highlight the relevance of creating measures to better understand SIB and related mortality in this age group. They also reveal the vulnerability of children in Brazil and warrant further studies to address these issues.

Background: Many countries have shown marked declines in diarrhoeal disease mortality among children younger than 5 years. With this analysis, we provide updated results on diarrhoeal disease mortality among children younger than 5 years from the Global Burden of Diseases, Injuries, and Risk Factors Study 2017 (GBD 2017) and use the study's comparative risk assessment to quantify trends and effects of risk factors, interventions, and broader sociodemographic development on mortality changes in 195 countries and territories from 1990 to 2017., Methods: This analysis for GBD 2017 had three main components. Diarrhoea mortality was modelled using vital registration data, demographic surveillance data, and verbal autopsy data in a predictive, Bayesian, ensemble modelling tool; and the attribution of risk factors and interventions for diarrhoea were modelled in a counterfactual framework that combines modelled population-level prevalence of the exposure to each risk or intervention with the relative risk of diarrhoea given exposure to that factor. We assessed the relative and absolute change in diarrhoea mortality rate between 1990 and 2017, and used the change in risk factor exposure and sociodemographic status to explain differences in the trends of diarrhoea mortality among children younger than 5 years., Findings: Diarrhoea was responsible for an estimated 533 768 deaths (95% uncertainty interval 477 162-593 145) among children younger than 5 years globally in 2017, a rate of 78·4 deaths (70·1-87·1) per 100 000 children. The diarrhoea mortality rate ranged between countries by over 685 deaths per 100 000 children. Diarrhoea mortality per 100 000 globally decreased by 69·6% (63·1-74·6) between 1990 and 2017. Among the risk factors considered in this study, those responsible for the largest declines in the diarrhoea mortality rate were reduction in exposure to unsafe sanitation (13·3% decrease, 11·2-15·5), childhood wasting (9·9% decrease, 9·6-10·2), and low use of oral rehydration solution (6·9% decrease, 4·8-8·4)., Interpretation: Diarrhoea mortality has declined substantially since 1990, although there are variations by country. Improvements in sociodemographic indicators might explain some of these trends, but changes in exposure to risk factors-particularly unsafe sanitation, childhood growth failure, and low use of oral rehydration solution-appear to be related to the relative and absolute rates of decline in diarrhoea mortality. Although the most effective interventions might vary by country or region, identifying and scaling up the interventions aimed at preventing and protecting against diarrhoea that have already reduced diarrhoea mortality could further avert many thousands of deaths due to this illness., Funding: Bill & Melinda Gates Foundation., (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: Despite large reductions in under-5 lower respiratory infection (LRI) mortality in many locations, the pace of progress for LRIs has generally lagged behind that of other childhood infectious diseases. To better inform programmes and policies focused on preventing and treating LRIs, we assessed the contributions and patterns of risk factor attribution, intervention coverage, and sociodemographic development in 195 countries and territories by drawing from the Global Burden of Diseases, Injuries, and Risk Factors Study 2017 (GBD 2017) LRI estimates., Methods: We used four strategies to model LRI burden: the mortality due to LRIs was modelled using vital registration data, demographic surveillance data, and verbal autopsy data in a predictive ensemble modelling tool; the incidence of LRIs was modelled using population representative surveys, health-care utilisation data, and scientific literature in a compartmental meta-regression tool; the attribution of risk factors for LRI mortality was modelled in a counterfactual framework; and trends in LRI mortality were analysed applying changes in exposure to risk factors over time. In GBD, infectious disease mortality, including that due to LRI, is among HIV-negative individuals. We categorised locations based on their burden in 1990 to make comparisons in the changing burden between 1990 and 2017 and evaluate the relative percent change in mortality rate, incidence, and risk factor exposure to explain differences in the health loss associated with LRIs among children younger than 5 years., Findings: In 2017, LRIs caused 808 920 deaths (95% uncertainty interval 747 286-873 591) in children younger than 5 years. Since 1990, there has been a substantial decrease in the number of deaths (from 2 337 538 to 808 920 deaths; 65·4% decrease, 61·5-68·5) and in mortality rate (from 362·7 deaths [330·1-392·0] per 100 000 children to 118·9 deaths [109·8-128·3] per 100 000 children; 67·2% decrease, 63·5-70·1). LRI incidence declined globally (32·4% decrease, 27·2-37·5). The percent change in under-5 mortality rate and incidence has varied across locations. Among the risk factors assessed in this study, those responsible for the greatest decrease in under-5 LRI mortality between 1990 and 2017 were increased coverage of vaccination against Haemophilus influenza type b (11·4% decrease, 0·0-24·5), increased pneumococcal vaccine coverage (6·3% decrease, 6·1-6·3), and reductions in household air pollution (8·4%, 6·8-9·2)., Interpretation: Our findings show that there have been substantial but uneven declines in LRI mortality among countries between 1990 and 2017. Although improvements in indicators of sociodemographic development could explain some of these trends, changes in exposure to modifiable risk factors are related to the rates of decline in LRI mortality. No single intervention would universally accelerate reductions in health loss associated with LRIs in all settings, but emphasising the most dominant risk factors, particularly in countries with high case fatality, can contribute to the reduction of preventable deaths., Funding: Bill & Melinda Gates Foundation., (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.)

Reducing child mortality is a key global health challenge. We examined reasons for greater or lesser success in meeting under-five mortality rate reductions, i.e. Millennium Development Goal #4, between 1990 and 2015 in Sub-Saharan Africa where child mortality remains high. We first examined factors associated with child mortality from all World Health Organization African Region nations during the Millennium Development Goal period. This analysis was followed by case studies of the facilitators and barriers to Millennium Development Goal #4 in four countries - Kenya, Liberia, Zambia, and Zimbabwe. Quantitative indicators, policy documents, and qualitative interviews and focus groups were collected from each country to examine factors within and across countries related to child mortality. We found familiar themes that highlighted the need for both specific services (e.g. primary care access, emergency obstetric and neonatal care) and general management (e.g. strong health governance and leadership, increasing community health workers, quality of care). We also identified methodological opportunities and challenges to assessing progress in child health, which can provide insights to similar efforts during the Sustainable Development Goal period. Specifically, it is important for countries to adapt general international goals and measurements to their national context, considering baseline mortality rates and health information systems, to develop country-specific goals. It will also be critical to develop more rigorous measurement tools and indicators to accurately characterize maternal, neonatal, and child health systems, particularly in the area of governance and leadership. Valuable lessons can be learned from Millennium Development Goal successes and failures, as well as how they are evaluated. As countries seek to lower child mortality further during the Sustainable Development Goal period, it will be necessary to prioritize and support countries in quantitative and qualitative data collection to assess and contextualize progress, identifying areas needing improvement.