Reducing child mortality to achieve MDG 4: WHO

7.6 million children under five years of age died in 2010 – nearly 21 000 children each day and almost 900 every hour. Progress has been made in recent decades, but is unequally distributed across regions and countries and within countries. Important challenges remain for the global goal to be achieved

Mortality

7.6 millionchildren under five years of age died in 2010. 

Situation

Just under 8 million under-five children died in 2010; nearly 21 000 children every day. Three-quarters of these deaths were concentrated in just two regions of the world: 46% in the African Region and 28% in South-East Asia. More than half of all child deaths were clustered in only six countries: India, Nigeria, Democratic Republic of the Congo, Pakistan, China, and Ethiopia. Regionally, the highest child mortality rates were in Africa (119 deaths per 1000 live births) and in the Eastern Mediterranean Region (68 deaths per 1000 live births). The risk of a child dying in low-income countries before completing five years of age is nearly 18 times the average for developed regions. Within countries, under-five mortality is higher among children living in rural areas and in the poorest households.

Some 70% of the world’s under-five deaths in 2010 occurred in only 15 countries, and about half in only five countries: India, Nigeria, Democratic Republic of the Congo, Pakistan and China. India (22%) and Nigeria (11%) together account for a third of under-five deaths worldwide.

---

Trends

Overall, substantial progress has been made towards achieving MDG 4. About 12 000 fewer children died every day in 2010 than in 1990, the baseline year for measuring progress. Improvement in child survival is evident in all regions. The number of countries with under-five mortality rates of 100 deaths per 1000 live births or higher has been halved from 52 in 1990 to 26 in 2010.

Globally, under-five mortality has decreased by 35%, from an estimated rate of 88 deaths per 1000 live births in 1990 to 57 deaths per 1000 live births in 2010. This decline translates into an average annual decrease in child mortality of 2.2%, which remains insufficient to achieve the MDG 4 target of reducing under-five mortality rates by two-thirds between 1990 and 2015. Numbers of under-five deaths have declined from 12.0 million in 1990 to 7.6 million in 2010. While progress has been made, it is unequally distributed. At the regional level, the decline in under-five mortality rates between 1990 and 2010 were more than 50% in three regions: Europe, the Americas and the Western Pacific Region. The highest observed average annual rates of reduction were seen in the European Region (4.4%), nearly three times higher than the rates observed in the African (1.8%) and in the Eastern Mediterranean (1.9%) regions.

As under-five mortality rates have fallen more sharply in richer developing regions, the disparity between Sub-Saharan Africa and other regions has grown. In 1990 a child born in Sub-Saharan Africa faced a probability of dying before age 5 that was 1.5 times higher than in Southern Asia, 3.2 times higher than in Latin America and the Caribbean, 3.7 times higher than in Eastern Asia and 11.8 times higher than in developed regions. By 2010 that probability was 1.8 times higher than in Southern Asia, 5.2 times higher than in Latin America and the Caribbean, 6.6 times higher than in Eastern Asia and 17.7 times higher than in developed regions. The disparity between Southern Asia and richer regions has also grown, though not as much.

Causes of death

58%of deaths in children under age five are caused by infectious diseases. Pneumonia is the largest single cause of death in under-fives. 

Situation

Globally, the four major killers of children under age five were pneumonia (18%), prematurity (16%: 14% during the neonatal period and 2% in the post-neonatal period), diarrhoeal diseases (11%), and birth asphyxia (10%: 9% during the neonatal period and 1% in the post-neonatal period). Malaria was still a major killer in Sub-Saharan Africa, causing about 15 percent of under-five deaths in the region.

Of the total 7.6 million children who died before 5 years of age, 4.4 million (58%) died of infectious diseases. Of all infections, pneumonia (1.4 million), diarrhoea (800 000) and malaria (563 000) were the leading causes of death, accounting together for 36% of all under-five deaths worldwide. The majority of these deaths can be prevented by known, simple, affordable and low cost interventions such as exclusive breastfeeding up to 6 months of age, immunization, appropriate use of antibiotics, oral rehydration therapy and zinc, insecticide treated bednets, and anti-malarials.

About 40% of deaths in children younger than 5 years occurred before 28 days of life – the neonatal period. The most important cause of death was preterm birth complications. Birth asphyxia and sepsis were the second and third major causes of death in this early period of life, responsible together for 1.2 million deaths. The risk of dying from these conditions can be mitigated with quality care during pregnancy, safe and clean delivery by a skilled attendant, and immediate postnatal care, including neonatal resuscitation, extra care of low birth weight babies, attention to baby warmth, treatment of neonatal sepsis and early initiation of breastfeeding.

---

Distribution

Patterns of the distribution of causes of child deaths vary widely between regions. The lowest proportion of neonatal deaths (30%) occurred in the African Region. On the other hand 96% of all under-five deaths due to malaria and 89% of all deaths due to HIV/AIDS worldwide happened in the African Region. In the remaining five WHO regions, high proportions of under-five child deaths occurred during the neonatal period, ranging from 42% in the Eastern Mediterranean Region to 54% in the Western Pacific Region. The proportion of deaths from pneumonia is lowest in the Americas and Europe. Deaths due to diarrhoeal diseases were responsible for only 4% of deaths in these same regions.

---

Trends

The number of under-five deaths worldwide dropped from 12 million in 1990 to 9.6 million in the year 2000 to 7.6 in 2010. Nearly 60% of the 2 million lives saved in the past decade were due to reductions of deaths caused by pneumonia (455 000 fewer deaths), measles (363 000 fewer deaths), and diarrhoea (361 000 fewer deaths). India, Nigeria, Democratic Republic of the Congo, Pakistan, and China contributed to half the mortality attributable to infections and more than half due to neonatal causes worldwide.

Preventing under-five deaths

78%of children with suspected pneumonia are taken for treatment to an appropriate care provider. 

Situation and trends

Pneumonia is responsible for the deaths of about 1.4 million children under-five annually. Addressing the major risk factors for the illness (malnutrition and indoor air pollution), along with vaccination, is essential for preventing the occurrence of the disease. For deaths to be averted, good quality care is crucial. Vital treatment tools for pneumonia include antibiotics and oxygen.

Appropriate care of the sick child is defined as providers that can correctly diagnose and treat pneumonia. Recent surveys indicate that, worldwide, 78% of children under-five with symptoms of pneumonia are taken to an appropriate provider; in low-income countries, this coverage is 43%. Antibiotics have an essential role in reducing deaths due to pneumonia. In low-income countries, less than one-third (29%) of under-five children with symptoms of pneumonia receive this treatment. Although some 451 000 lives have been saved in the last decade due to the pneumonia deaths averted, estimates suggest that the number of lives saved could reach almost 1 million if both prevention and treatment interventions to reduce pneumonia were universally delivered. Children living in rural areas, poor children, and children with poorly educated mothers are less likely to be taken to appropriate care, as compared to children from urban areas, wealthier families, and those with more educated caregivers.

Some progress has been made in care seeking for pneumonia in recent years. However, accelerated and more aggressive efforts should be taken to scale up effective interventions. It is estimated that only 29% of children with pneumonia in low-income countries receive antibiotics for treatment. In some of these countries, coverage is as low as 10%. Nevertheless, progress is possible – countries such as Egypt and Colombia have been able to significantly increase antibiotic coverage in a relatively short period of time.

Source: WHO

Urbanization in Asia has health consequences for People in Urban slum...???

Can you describe the urbanization of Asia?

More and more people are moving to cities in Asia, so much so that the number of people living in urban areas on the continent is expected to increase from one and a half billion to two billion by 2016. If we do not include Japan in the mix, Asia is projected to increase from the current 38 percent urban to 50 percent urban by 2025. The urban population growth in Asia is 2.3 compared to 0.14 in Europe. The number of cities with populations of one million or more is likely to increase from 194 to 288 by 2015. Many cities in the region are pushing beyond their limits and are merging into massive new mega-regions, which are linked both physically and economically. Their expansion drives economic growth but also leads to urban sprawl, rising inequalities and urban unrest.

In Asia, the biggest mega-regions are at the forefront of the rapid urbanization. They include Hong Kong-Shenzhen-Guangzhou, China—home to about 120 million people. The same trend on an even larger scale is seen in fast-growing “urban corridors” such as Mumbai to Delhi in India. Other major cities in the region with huge urban health challenges include Dhaka, Jakarta and Karachi.

Who is affected?

Urbanization affects everyone in one way or another. Unfortunately, the poor and marginalized are the groups most affected by urbanization. Women, children and the elderly among the poor bear the brunt of the effects, given that maternal and child health and survival statistics in the urban slums are particularly dismal. Though a large number of people migrate to urban areas with the hope of achieving better economic and health status, their health conditions are similar to or worse than those of rural populations and far worse than urban averages. For example, there is marked childhood under-nutrition in urban slums, maternal mortality rates are similar to those of rural areas and access to health services is extremely limited. In India, nearly one million babies are born every year in the urban slums.

What are the health implications of urbanization in Asia?

Urban health has remained a low priority in most Asian countries, with greater focus on rural areas in the past many decades. Credible data for urban poor, which could help in planning for better services and living conditions, are lacking. Because the urban poor are often living illegally, many clusters are overlooked by official demographers. As a result, there are numerous invisible and uncounted slums in many of the region’s countries. With poor to no planning for the slums, primary health and nutrition services available to women and their families and other residents are inadequate. The health systems continue to invest in curative services, paying no attention to primary services in the urban areas. There is weak coordination among various stakeholders including governments and NGOs. Very few examples of coordinated, planned slum health programs exist in these areas. The poor end up with limited access to public health services and an inadequate system to refer them from community to primary health facilities.

Risk pooling and health insurance mechanisms for the poor are limited, middle and higher income populations use public hospitals disproportionately and hospitals are overused for minor ailments.

In addition, there is low awareness about healthy behaviors; weak community organization and social cohesion; lack of trust in public sector services owing to irregularity and low quality; lack of family support to the mother/caregiver; and a pressing need for the mother to return to work after childbirth.

Temporary and recent migrants are often denied access to health services and are difficult to track for follow-up care. In urban slums, the prevalence of diarrhea, fever and cough among children is high. Water and sanitation conditions are grim. To make matters worse, alcoholism, substance abuse, gender inequity and poor educational status are widespread.

How can health implications of urbanization be addressed?

The encouraging news is that there is growing recognition of the issues and increasing interest among governments, donors and NGOs. However, we still have a lot to learn about the issues of urbanization. A comprehensive effort must be undertaken to identify, plot and assess clusters of urban poor. Understanding the local context is the key to effective urban health programs. It is important to increase the ability of institutions in slums to deal with these issues and facilitate linkages with public and private sector providers to ensure sustained care and services. Other agencies and groups within and outside government—such as public works, engineering, labor and education—could play a role in dealing with issues such as water and sanitation in the slums.

Based on conversation with Jhpiego’s South Asia expert Dr. Nabeel Akram.

MDG: Progress towards the health-related Millennium Development Goals: WHO

---

Key facts

• Fewer children are dying. Annual global deaths of children under five years of age fell to 8.1 million in 2009 from 12.4 million in 1990.
• Fewer children are underweight. The percentage of underweight children under five years old is estimated to have dropped from 25% in 1990 to 16% in 2010.
• More women get skilled help during childbirth. The proportion of births attended by a skilled health worker has increased globally, however, in the WHO Africa and South-East Asia regions fewer than 50% of all births were attended.
• Fewer people are contracting HIV. New HIV infections have declined by 17% globally from 2001–2009.
• Tuberculosis treatment is more successful. Existing cases of TB are declining, along with deaths among HIV-negative TB cases.
• More people have safe drinking-water, but not enough have toilets. The world is on track to achieve the MDG target on access to safe drinking-water but more needs to be done to achieve the sanitation target.

---

In September 2000, 189 heads of state adopted the UN Millennium Declaration and endorsed a framework for development. The plan was for countries and development partners to work together to reduce poverty and hunger, tackle ill-health, gender inequality, lack of education, lack of access to clean water and environmental degradation.

They established eight Millennium Development Goals (MDGs), with targets set for 2015, and identified a number of indicators to monitor progress, several of which relate directly to health. All the goals and their targets are measured in terms of progress since 1990. Reporting on progress towards the MDGs has underscored the importance of producing more reliable and timely data.

Progress report on the health-related MDGs

While some countries have made impressive gains in achieving health-related targets, others are falling behind. Often the countries making the least progress are those affected by high levels of HIV/AIDS, economic hardship or conflict.

Detailed updates on the progress

Please note that the following statistics are estimates.

Halve, between 1990 and 2015, the proportion of people who suffer from hunger (MDG 1, target 1.C)

Children's nutrition has improved. The percentage of underweight children is estimated to have declined from 25% in 1990 to 16% in 2010. But 104 million children are still undernourished. Stunting in children under five years old has decreased globally from 40% to 27% over the same period. However, in the UN Africa Region, the number of stunted children is estimated to have increased from 45 million in 1990 to 60 million in 2010.

Reduce child mortality (MDG 4)

Annual deaths of children under five years of age in 2009 fell to 8.1 million, down by 35% from 1990. The rate of decline has doubled to 2.7% per year since 2000, compared to the previous decade (1.3%). The deaths of nearly 3 million children under five each year worldwide can be attributed to diarrhoea and pneumonia. An estimated 40% of deaths in children under five occur in the first month of life, so improving newborn care is essential for further progress. The coverage of infants immunized against measles increased from 73% to 82% from 1990 to 2009.

Improve maternal health (MDG 5)

The number of women dying as a result of complications during pregnancy and childbirth has decreased by 34% – from 546 000 in 1990 to 358 000 in 2008. Although the progress is notable, the annual rate of decline of 2.3% is less than half of the 5.5% needed to achieve the target. Almost all maternal deaths (99%) in 2008 occurred in developing countries.

From 2000 to 2010 just over half of all pregnant women made the WHO-recommended minimum of four antenatal visits. While the global proportion of births attended by a skilled health worker has increased, in the WHO regions of Africa and South-East Asia fewer than half of all births had skilled assistance.

Globally, contraceptive use has been on the rise, annually increasing 0.2% since 2000. From 2000 to 2008 there were 48 births per 1000 adolescent girls aged 15–19 globally.

Combat HIV/AIDS, malaria, and other diseases (MDG 6)

HIV/AIDS

From 2001 to 2009 new HIV infections worldwide declined by 17%. In 2009, 2.6 million people contracted the virus and there were 1.8 million HIV/AIDS-related deaths. In 2009, around 53% of the 1.4 million HIV-positive, pregnant women in low- and middle-income countries received antiretroviral therapy (ART) to prevent the transmission of HIV to their babies. More than 5 million people in low- and middle-income countries were receiving ART by the end of 2009 but that left more than 9 million untreated HIV-positive people in these countries.

Tuberculosis

Despite a rise in the number of new tuberculosis (TB) cases worldwide – due to an increase in population – more people are being successfully treated. TB mortality among HIV-negative people has dropped from 30 deaths per 100 000 people in 1990 to 20 deaths per 100 000 in 2009. However, HIV-associated TB and multidrug-resistant TB are harder to diagnose and cure.

Malaria

Indications are that 42 countries are on course to meet the MDG target for reducing malaria; in 2009 an estimated 225 million cases of malaria caused 781 000 deaths, mostly of children under five. The supply of insecticide-treated nets increased but need outweighed availability almost everywhere. Access to antimalarial medicines (especially artemisinin-based combination therapy) increased but it was inadequate in all countries surveyed in 2007 and 2008.

Other diseases

An estimated 1 billion people suffer from neglected tropical diseases. This includes lymphatic filariasis which in 2009 was endemic in 81 countries. There were over 220 000 cases of cholera reported in 2009, an increase over the previous year. In 2009, 244 617 cases of leprosy were reported, down from 5.2 million in 1985. In 2009, only 3190 cases of dracunculiasis were reported while in the 1989 the estimated number of cases was almost 900 000.

Halve, by 2015, the proportion of people without sustainable access to safe drinking water and basic sanitation (MDG 7, target 7.C)

Globally, the percentage of the world’s population with access to safe drinking-water increased from 77% to 87%, which is sufficient to reach the MDG target if the rate of improvement is maintained. In low-income countries, however, the annual rate of increase needs to double in order to reach the target and a gap persists between urban and rural areas in many countries.

In 2008, 2.6 billion people had no access to a hygienic toilet or latrine and 1.1 billion were defecating in the open. The slowest improvement has been in the WHO African Region, where the percentage of the population using toilets or latrines increased from 30% in 1990 to 34% in 2008. Inadequate sewerage spreads infections such as schistosomiasis, trachoma, viral hepatitis and cholera.

In cooperation with pharmaceutical companies, provide access to affordable essential medicines in developing countries (MDG 8, target 8.E)

Although nearly all countries publish an essential medicines list, the availability of medicines at public-health facilities is often poor. Surveys conducted in over 40 low-income countries show that 44% of public sector and 65% of private sector outlets had the listed generic medicines in stock. Lack of medicines in the public sector forces patients to go without or purchase medicines from private sector outlets where generic medicines cost on average 610% more than their international reference price.

Source: WHO