<< Back To Home

THE CHILD SURVIVAL REVOLUTION: WHAT NEXT?

Wednesday, 17th of September 2014

THE CHILD SURVIVAL REVOLUTION: WHAT NEXT?

The Lancet, Volume 384, Issue 9947, Pages 931 - 933, 13 September 2014

Best viewed, with graphics and weblinks, at

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2814%2961057-6/fulltext

Joy E Lawn a

A child born today has half the risk of dying before their fifth birthday compared with a child born in 1990, the baseline of the Millennium Development Goals (MDGs), when 12·2 million children died, now reduced to 6·3 million (95% uncertainty interval 6·0—6·6 million).1 In The Lancet, Haidong Wang and colleagues1 from the Institute of Health Metrics and Evaluation (IHME) present complex analyses, the most detailed attempt yet to attribute change and predict the future post-2015 for child survival.

Wang and colleagues1 estimate that the under-5 mortality rate reduced from a global average of 83·1 per 1000 livebirths (95% uncertainty interval 68·9—98·2) in 1990, to 43·3 per 1000 (32·9—57·3) in 2013. This proportionate reduction is similar to UN estimates of a reduction from 90 per 1000 livebirths in 1990 to 48 per 1000 in 2012.2 Because inputs for two-thirds of deaths worldwide depend on household surveys with a 5-year time lag, major data gaps exist in recent years. Even countries with usable vital registration have not yet submitted 2013 data.3 However, despite uncertainties, enough data are available to show remarkable mortality risk reductions. Estimates from IHME and the UN have increased the frequency, complexity, and transparency of estimation with convergence worldwide, although differences remain between countries.1 Yet many national policy makers continue to use national household survey data and not global estimates.4

Progress in child survival has changed gear with a recent doubling of the average annual rate of reduction to 3·5% in 2005—13, coinciding with increased attention and funding.1 The mid-1990s marked the slowest progress with an average annual rate of change of −1·2, stagnating compared with average annual rates of reduction of between 2·5% and 3·0% in 1970—80s.1 Although other factors played a part in the 1990s, especially in Africa, notably structural adjustment and an unchecked HIV epidemic, there is recognition that the UN and global community lost focus during the 1990s. There is real concern among national and global health policymakers that recent remarkable progress might again stall after 2015. Outcome-focused targets are fundamental to maintaining attention and accountability, and yet these targets are still unclear in the post-2015 framework, despite being crucial in A Promise Renewed, the African Unions Campaign for Reduction of Maternal Mortality, and the Muskoka initiative.

An important gap is our understanding of the drivers of rapid mortality change, and conversely what has impeded progress in the 17 slowest progressing countries identified by Wang and colleagues (including the USA).1 IHMEs mixed-effects model explains a remarkable 94% of the mortality rate change since 1990. Investigators applied Shapley decomposition to 64 scenarios to attribute average changes for covariates assessed. The identified factors were secular trend, maternal education, and less progress explained by income.1 When considering numbers, Africas child survival progress has been curtailed by the continuing increase in births, and a smaller effect from increased HIV/AIDS.1 Hence, secular trend is the main explanatory variable in this model. What is this secular trend and how do we scale it up? Is this improved environment, or shifts in social norms? Or better transport or communications? Or can it be directly attributed to health-care technologies, some of which have had major changes in coverage (notably immunisation, HIV/AIDS, and malaria interventions)?

Can modelling account for co-linearity of income, education, and reduced family size with other unnamed, more proximal health-care parameters?5 As well as complex modelling, we urgently need rigorous standardised assessments to assess success factors and get beyond statistical associations alone, or platitudes regarding governance and leadership, and more into the how to of national change (or lack of it). Some countries with poor governance and little economic growth have made remarkable progress for maternal mortality and child survival, notably Bangladesh.5—7 Are these paradoxes context-specific or would solutions transfer from Bangladesh to Nigeria, for example? Families in countries with the highest mortality risks cannot wait for perfect governance.

What does this mean for the future? The MDG endline of 2015 is a moment to pause, look back, learn, and gather speed. Momentum cannot be lost as it was in the late 1990s (table). If optimistic mortality trends and fertility trends are achieved then, by 2030, 2·4 million children will die yearly,1 of which most would be neonatal deaths.2, 5, 8 We need to use data to drive accelerated change, and to do so we need to understand that change better.

TableTable image

Child survival revolution, past and future

Where to focus? Africas share of both child and maternal deaths has increased—now with 12% of world population yet more than 50% of maternal and child deaths.2 According to Wang and colleagues, all eight countries predicted to have under-5 mortality of more than 70 per 1000 livebirths in 2030 are African.1 Many of these are affected by conflict. Pakistan and Afghanistan are highlighted in other analyses.2, 5, 8

When to focus? Wang and colleagues note the changing age structure of child deaths, with rising importance of the neonatal period (first 4 weeks) and indeed early neonatal period (first week). Both IHME and the UN have recently addressed previous simplistic assumptions where the under-5 mortality rate in high HIV countries inflated the neonatal mortality rate.9 However, IHMEs modelled proportion of under-5 mortality that is neonatal is now lower than the UNs and remains virtually flat until 2030, when it is predicted to still be around 44%, which suggests that the IHME model does not capture neonatal mortality rate trends differentially to under-5 mortality rate trends.1 There is already a notable divergence for IHME neonatal mortality estimates in some countries with recent real data such as those from Pakistan.10 An elegant analysis in Brazil showed that the median day of infant death had shifted from day 30 in 1979 to day 3 in 2007.11 In most world regions half or more of child deaths are in the neonatal period, with the hours around birth being those with the greatest risk of death and disability, and requiring more attention given feasible and cost-effective interventions.8

What should the child survival revolution focus on next? The first revolution led by Jim Grant had a rallying call for growth, oral rehydration salts, breastfeeding, immunisation, food supplementation, fertility, and female education (GOBI—FFF; table).6 From GOBI-FFF, family planning and female education received less focus and yet, according to Wang and colleagues analysis,1 these are potentially the biggest drivers of child survival, also affecting womens empowerment and human development. During the past decade, the second child survival revolution has been fragmented and driven by selective investments in immunisation, HIV/AIDS, and malaria, but has lacked broader preventive care such as breastfeeding, water, and sanitation and has only recently focused more on care of children with pneumonia, diarrhoea, and undernutrition.12 Care of newborn babies has been almost entirely neglected, but preterm birth complications alone account for as many deaths as pneumonia and 10-fold more than does AIDS in children.8

We are the first generation able to envision a grand convergence in survival, in which child and maternal mortality in the poorest countries reach the levels of the richest.13 To achieve this, present mortality reduction trends need to be doubled and intentional investment must reach the poorest with the highest effect of care. In addition to completion of the unfinished business for pneumonia, diarrhoea, malaria, and HIV, a major shift needs to prioritise a healthy start, through quality of care at birth for every woman, and improved care of small and sick newborn babies. The Lancet Every Newborn series8 details the evidence, and the Every Newborn Action Plan is gaining momentum. This healthy start also improves human capital, targeting disability, preterm birth, small for gestational age, and stunting. The next child survival revolution has to go beyond survival alone to counting child development outcomes. The post-2015 framework needs explicit targets for maternal mortality, under-5 mortality, and neonatal mortality, but also for stillbirths and development outcomes. However a gap remains for effective accountability mechanisms and leadership for national change (table).

Finally, clever modelling is no panacea for poor input data. Counting births and deaths is not just about a piece of paper, but a shift in norms to show that every birth and every death counts and that millions of newborn and child deaths are not inevitable.8

For the Campaign for Reduction of Maternal Mortality in Africa see http://www.carmma.org/

For A Promise Renewed see http://www.apromiserenewed.org/

For the Every Newborn Action Plan see http://www.everynewborn.org/

For the Muskoka Initiativehttp://www.acdi-cida.gc.ca/acdi-cida/acdi-cida.nsf/En/FRA-119133138-PQT

I am an unpaid member of both the IHME Global Burden of Disease Scientific Review Group and WHOs Global Statistics Advisory Board.

References

1 Wang H, Liddell CA, Coates MM, et al. Global, regional, and national levels of neonatal, infant, and under-5 mortality during 1990—2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2014; 384: 957-979. Summary | Full Text | PDF(9629KB) | PubMed

2 UNICEF. Levels and trends in child mortality. New York: United Nations, 2013. http://www.childinfo.org/files/Child_Mortality_Report_2013.pdf. (accessed May 24, 2014).

3 Oestergaard MZ, Alkema L, Lawn JE. Millennium Development Goals national targets are moving targets and the results will not be known until well after the deadline of 2015. Int J Epidemiol 2013; 42: 645-647. PubMed

4 Byass P. The imperfect world of global health estimates. PLoS Med 2010; 7: e1001006. PubMed

5 Lawn JE, Kinney M, Black RE, et al. A decade of change for newborn survival, policy and programmes: a multi-country analysis. Health Policy Plan 2012; 27 (suppl 3): 6-28. PubMed

6 Rohde J, Cousens S, Chopra M, et al. 30 years after Alma-Ata: has primary health care worked in countries?. Lancet 2008; 372: 950-961. Summary | Full Text | PDF(231KB) | PubMed

7 Adams AM, Rabbani A, Ahmed S, et al. Explaining equity gains in child survival in Bangladesh: scale, speed, and selectivity in health and development. Lancet 2013; 382: 2027-2037. Summary | Full Text | PDF(1070KB) | PubMed

8 Lawn JE, Blencowe H, Oza S, et al. Every Newborn: progress, priorities, potential beyond survival. Lancet 2014. published online May 19. http://dx.doi.org/10.1016/S0140-6736(14)60496-7.

9 Kerber KJ, Lawn JE, Johnson LF, et al. South African child deaths 1990—2011: have HIV services reversed the trend enough to meet Millennium Development Goal 4?. AIDS 2013; 27: 2637-2648. PubMed

10 National Institute of Population Studies. Pakistan Demographic and Health Survey 2012—13. Preliminary report. http://dhsprogram.com/publications/publication-FR290-DHS-Final-Reports.cfm. (accessed July 7, 2014).

11 Victora CG, Aquino EM, do Carmo Leal M, Monteiro CA, Barros FC, Szwarcwald CL. Maternal and child health in Brazil: progress and challenges. Lancet 2011; 377: 1863-1876. Summary | Full Text | PDF(480KB) | PubMed

12 Bryce J, Victora CG, Black RE. The unfinished agenda in child survival. Lancet 2013; 382: 1049-1059. Summary | Full Text | PDF(299KB) | PubMed

13 Stenberg K, Axelson H, Sheehan P, et al. Advancing social and economic development by investing in womens and childrens health: a new Global Investment Framework. Lancet 2014; 383: 1333-1354. Summary | Full Text | PDF(960KB) | PubMed

a London School Hygiene & Tropical Medicine, London WC1E 7HT, UK