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. 2021 Sep 4;398(10303):870-905.
doi: 10.1016/S0140-6736(21)01207-1. Epub 2021 Aug 17.

Global, regional, and national progress towards Sustainable Development Goal 3.2 for neonatal and child health: all-cause and cause-specific mortality findings from the Global Burden of Disease Study 2019

GBD 2019 Under-5 Mortality Collaborators
Collaborators

Global, regional, and national progress towards Sustainable Development Goal 3.2 for neonatal and child health: all-cause and cause-specific mortality findings from the Global Burden of Disease Study 2019

GBD 2019 Under-5 Mortality Collaborators. Lancet. .

Abstract

Background: Sustainable Development Goal 3.2 has targeted elimination of preventable child mortality, reduction of neonatal death to less than 12 per 1000 livebirths, and reduction of death of children younger than 5 years to less than 25 per 1000 livebirths, for each country by 2030. To understand current rates, recent trends, and potential trajectories of child mortality for the next decade, we present the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 findings for all-cause mortality and cause-specific mortality in children younger than 5 years of age, with multiple scenarios for child mortality in 2030 that include the consideration of potential effects of COVID-19, and a novel framework for quantifying optimal child survival.

Methods: We completed all-cause mortality and cause-specific mortality analyses from 204 countries and territories for detailed age groups separately, with aggregated mortality probabilities per 1000 livebirths computed for neonatal mortality rate (NMR) and under-5 mortality rate (U5MR). Scenarios for 2030 represent different potential trajectories, notably including potential effects of the COVID-19 pandemic and the potential impact of improvements preferentially targeting neonatal survival. Optimal child survival metrics were developed by age, sex, and cause of death across all GBD location-years. The first metric is a global optimum and is based on the lowest observed mortality, and the second is a survival potential frontier that is based on stochastic frontier analysis of observed mortality and Healthcare Access and Quality Index.

Findings: Global U5MR decreased from 71·2 deaths per 1000 livebirths (95% uncertainty interval [UI] 68·3-74·0) in 2000 to 37·1 (33·2-41·7) in 2019 while global NMR correspondingly declined more slowly from 28·0 deaths per 1000 live births (26·8-29·5) in 2000 to 17·9 (16·3-19·8) in 2019. In 2019, 136 (67%) of 204 countries had a U5MR at or below the SDG 3.2 threshold and 133 (65%) had an NMR at or below the SDG 3.2 threshold, and the reference scenario suggests that by 2030, 154 (75%) of all countries could meet the U5MR targets, and 139 (68%) could meet the NMR targets. Deaths of children younger than 5 years totalled 9·65 million (95% UI 9·05-10·30) in 2000 and 5·05 million (4·27-6·02) in 2019, with the neonatal fraction of these deaths increasing from 39% (3·76 million [95% UI 3·53-4·02]) in 2000 to 48% (2·42 million; 2·06-2·86) in 2019. NMR and U5MR were generally higher in males than in females, although there was no statistically significant difference at the global level. Neonatal disorders remained the leading cause of death in children younger than 5 years in 2019, followed by lower respiratory infections, diarrhoeal diseases, congenital birth defects, and malaria. The global optimum analysis suggests NMR could be reduced to as low as 0·80 (95% UI 0·71-0·86) deaths per 1000 livebirths and U5MR to 1·44 (95% UI 1·27-1·58) deaths per 1000 livebirths, and in 2019, there were as many as 1·87 million (95% UI 1·35-2·58; 37% [95% UI 32-43]) of 5·05 million more deaths of children younger than 5 years than the survival potential frontier.

Interpretation: Global child mortality declined by almost half between 2000 and 2019, but progress remains slower in neonates and 65 (32%) of 204 countries, mostly in sub-Saharan Africa and south Asia, are not on track to meet either SDG 3.2 target by 2030. Focused improvements in perinatal and newborn care, continued and expanded delivery of essential interventions such as vaccination and infection prevention, an enhanced focus on equity, continued focus on poverty reduction and education, and investment in strengthening health systems across the development spectrum have the potential to substantially improve U5MR. Given the widespread effects of COVID-19, considerable effort will be required to maintain and accelerate progress.

Funding: Bill & Melinda Gates Foundation.

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Conflict of interest statement

Declaration of interests Robert Ancuceanu reports consulting fees from AbbVie and AstraZeneca; payment or honoraria for lectures, presentations, speakers' bureaus, manuscript writing, or educational events from Sandoz and AbbVie; support for attending meetings and/or travel from AbbVie and AstraZeneca, all outside the submitted work. Marcel Ausloos reports grants or contracts from Romanian National Authority for Scientific Research and Innovation, CNDS-UEFISCDI, project number PN-III-P4-ID-PCCF-2016-0084, outside the submitted work. Ettore Beghi reports grants or contracts paid to their institutions from ALSA, the Italian Ministry of Health and SOBI; payment or honoraria for lectures, presentations, speakers' bureaus, manuscript writing, or educational events from Arvell Therapeutics; support for attending meetings and/or travel from ILAE and EAN, all outside the submitted work. Reinhard Busse reports leadership or fiduciary role in other board, society, committee, or advocacy group, paid or unpaid with the Robert Koch Institute as member of the scientific advisory committee, German Burden 2020 project, all outside the submitted work. Joao Conde reports grants or contracts from the European Research Council grant agreement No 848325 (ERC starting grant); patents planned issued or pending for TRPV2 antagonists WO2019054891 - Instituto de Medicina Molecular (PT), Hydrogel Particles, Compositions, and Methods- WO US US20170333304A1 - Massachusetts Institute of Technology (USA), and Theranostic nanoprobes for overcoming cancer multidrug resistance and methods- WO US WO2016134232A1 - Massachusetts Institute Of Technology (USA), all outside the submitted work. Irina Filip reports payment or honoraria for lectures, presentations, speakers' bureaus, manuscript writing, or educational events from Avicenna Medical and Clinical Research Institute. Claudiu Herteliu reports grants or contracts from Romanian National Authority for scientific research and innovation, CNDS-UEFISCDI, project number PN-III-P4-ID-PCCF-2016-0084, research grant (October, 2018, to September, 2022), understanding and modelling time–space patterns of psychology-related inequalities and polarisation, and project number PN-III-P2-2.1-SOL-2020-2-0351, research grant (June, 2021, to October, 2021), approaches within public health management in the context of COVID-19 pandemic, and from the Ministry of Labour and Social Justice Romania, project number 30/PSCD/2018, research grant (September, 2018 to June, 2019), agenda for skills Romania 2020–25, all outside the submitted work. Sheikh Mohammed Shariful Islam reports grants or contracts from National Health and Medical Research Council (NHMRC) and National Heart Foundation of Australia Fellowships, outside the submitted work. Jacek Jerzy Jozwiak reports payment or honoraria for lectures, presentations, speakers' bureaus, manuscript writing, or educational events from Teva, Amgen, Synexus, Boehringer Ingelheim, ALAB Laboratories, and Zentiva, all outside the submitted work. Nicholas J Kassebaum reports support for the present manuscript from the Bill & Melinda Gates Foundation as grant funding for the GBD. Kewal Krishan reports non-financial support from UGC Centre of Advanced Study, CAS II, Department of Anthropology, Panjab University, Chandigarh, India, outside the submitted work. Morteza Mahmoudi reports payment or honoraria for lectures, presentations, speakers' bureaus, manuscript writing, or educational events for his published books, plenary lectures, and licensed patent to Seer; leadership or fiduciary role in other board, society, committee or advocacy group, paid or unpaid with the Academic Parity Movement, a non-profit organisation dedicated to addressing academic discrimination, violence, and incivility, as a cofounder, all outside the submitted work. Shuhei Nomura reports support for the present manuscript from Ministry of Education, Culture, Sports, Science and Technology of Japan (MEXT) as grant funding. Adrian Pana reports grants or contracts from Romanian National Authority for Scientific Research and Innovation, CNDS-UEFISCDI, project number PN-III-P4-ID-PCCF-2016-0084, research grant (October, 2018, to September, 2022), understanding and modelling time-space patterns of psychology-related inequalities and polarisation, and project number PN-III-P2-2.1-SOL-2020-2-0351, research grant (June, 2021, to October, 2021), approaches within public health management in the context of COVID-19 pandemic, all outside the submitted work. Seithikurippu R Pandi-Perumal reports payment or honoraria for lectures, presentations, speakers' bureaus, manuscript writing, or educational events for the volumes he edited; leadership or fiduciary role in other board, society, committee, or advocacy group, paid or unpaid, with Somnogen Canada, Toronto, Canada, as the President and Chief Executive Officer, all outside the submitted work. Thomas Pilgrim reports grants or contracts from Biotronik, Boston Scientific, and Edwards Lifesciences; payment or honoraria for lectures, presentations, speakers' bureaus, manuscript writing, or educational events from Biotronik, Boston Scientific, and HighLifeSAS; and being proctor for Medtronic and Boston Scientific, all outside the submitted work. Maarten J Postma reports grants or contacts from Merck, Sharp & Dohme, GlaxoSmithKline, Pfizer, Boehringer Ingelheim, Novavax, Bayer, Bristol Myers Squibb, AstraZeneca, Sanofi, IQVIA, BioMerieux, WHO, EU, Seqirus, FIND, Antilope, DIKTI, LPDP, and Budi; consulting fees from Merck, Sharp & Dohme, GlaxoSmithKline, Pfizer, Boehringer Ingelheim, Novavax, Quintiles, Bristol Myers Squibb, AstraZeneca, Sanofi, Novartis, Pharmerit, IQVIA, and Seqirus; participation on a data safety monitoring board or advisory board to Asc Academics as adviser; stock or stock options in Health-Ecore and PAG, all outside the submitted work. Amir Radfar reports payment or honoraria for lectures, presentations, speakers' bureaus, manuscript writing, or educational events from Avicenna Medical and Clinical Research Institute. Jasvinder A Singh reports consulting fees from Crealta/Horizon, Medisys, Fidia, Two labs, Adept Field Solutions, Clinical Care options, Clearview health-care partners, Putnam associates, Focus forward, Navigant consulting, Spherix, MedIQ, UBM, Trio Health, Medscape, WebMD, and Practice Point communications, and the National Institutes of Health and the American College of Rheumatology; payment or honoraria for lectures, presentations, speakers' bureaus, manuscript writing, or educational events from Simply Speaking; support for attending meetings and travel from OMERACT, an international organisation that develops measures for clinical trials and receives arm's length funding from 12 pharmaceutical companies, when travelling biannually to OMERACT meetings; leadership or fiduciary role in other board, society, committee, or advocacy group, paid or unpaid, with OMERACT as a member of the steering committee, with the US Food and Drug Administration (FDA) Arthritis Advisory Committee, with the Veterans Affairs Rheumatology Field Advisory Committee as a member, and with the UAB Cochrane Musculoskeletal Group Satellite Center on Network Meta-analysis as a director and editor; stock or stock options in TPT Global Tech, Vaxart pharmaceuticals, Charlotte's Web Holdings, and previously owned stock options in Amarin, Viking, and Moderna pharmaceuticals, all outside the submitted work. Mark A Stokes reports payment or honoraria for lectures, presentations, speakers' bureaus, manuscript writing, or educational events at the Autism Teaching Institute (Victoria, Australia); unpaid participation on a data safety monitoring board or advisory board with the Deakin University Human Research Ethics Committee; leadership or fiduciary role in other board, society, committee, or advocacy group, paid or unpaid, with the Australasian Society for Autism Research as a past president, with the Australasian Society for Autism Research as a board member, with Kidsafe (Victoria, Australia) as vice president, with Mindful as a member of the research advisory board, and with Autism Teaching Institute as chair of the research advisory board; stock or stock options in Cochlear and Medical Developments, all outside the submitted work. Stefan Stortecky reports grants or contracts to their institute from Edwards Lifesciences, Medtronic, Boston Scientific, and Abbott; consulting fees from BTG and Teleflex; payment or honoraria for lectures, presentations, speakers' bureaus, manuscript writing, or educational events from BTG and Boston Scientific; support for attending meetings and/or travel from BTG, all outside the submitted work. Carolyn B Swope reports support for the present manuscript from Delos Living as a former employee; and consulting fees from Delos Living, outside the submitted work. Riaz Uddin reports grants or contracts from Alfred Deakin Postdoctoral Research Fellowship, Deakin University, Australia; support for attending meetings and/or travel from Deakin University Institute for Physical Activity and Nutrition, all outside the submitted work.

Figures

Figure 1
Figure 1
Global all-cause under-5 mortality by age, year, and SDI (A) Under-5 deaths (in millions) for 2000–19. (B) ARC in qx for each year between 2000 and 2019. (C) Proportion of under-5 deaths in 2000 compared with the ratio of age-specific to total under-5 absolute change in deaths between 2000 and 2015 by SDI quintile. (D) Proportion of under-5 deaths in 2015 compared to ratio of age-specific to total under-5 absolute change in deaths between 2015 and 2019 by SDI quintile. The shaded areas in panels A and B represent 95% uncertainty intervals. The black line in panels C and D represents line of equivalence, such that points above the line indicate age and SDI groups in which change outpaces overall under-5 mortality change and points below the line indicate age and SDI groups in which change underperforms relative to overall under-5 mortality change. ARC=annualised rate of change. qx=probability of death. SDI=Socio-demographic Index.
Figure 2
Figure 2
Map of individual countries' progress toward achieving the Sustainable Development Goals 3.2 target of (A) reducing neonatal mortality rate to the threshold of 12 neonatal deaths per 1000 livebirths, and reducing under-5 mortality rate to the threshold of 25 under-5 deaths per 1000 livebirths (B), under the reference scenario
Figure 3
Figure 3
Neonatal and remaining under-5 cause-specific mortality, by region and SDI Values presented are cause fractions: the proportion of total age-specific deaths with a particular underlying cause of death. Causes are presented at Level 2 in the hierarchy, with other non-communicable diseases disaggregated to include congenital birth defects, sudden infant death syndrome, haemoglobinopathies and haemolytic anaemias, endocrine, metabolic, blood, and immune disorders, and urinary diseases and male infertility separately. Total under-5 mortality is split at 28 days to include neonatal (<28 days) separately from children between 28 days and 5 years of age. SDI=Socio-demographic Index.
Figure 4
Figure 4
2019 NMR and U5MR by HAQ Index at the national level 204 countries were analysed, and the colour of each point indicates the SDI quintile that the country belongs to. HAQ Index ranges from 0 (worst) to 100 (best). The survival potential frontier, global optimum, and SDG targets are indicated as lines on the graph. Grey shaded bands represent 95% UIs. Countries are labelled with their ISO3 country code in bold when their ratio to the survival potential frontier is in the highest 10% of all countries and in italics when their ratio to the survival potential frontier is in the lowest 10% of all countries. ISO3 codes and corresponding location names are listed in the appendix (p 11). NMR=neonatal mortality rate. HAQ=Healthcare Access and Quality. SDG=Sustainable Development Goal. SDI=Socio-demographic Index. U5MR=under-5 mortality rate. UI=uncertainty interval.
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Comment in

  • Kindersterblichkeit weltweit rückläufig.
    Reinhardt D. Reinhardt D. MMW Fortschr Med. 2021 Nov;163(Suppl 3):29. doi: 10.1007/s15006-021-0563-7. MMW Fortschr Med. 2021. PMID: 34811678 Free PMC article. Review. German. No abstract available.

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