Millennium Development Goal 4 (MDG 4): Reduce child mortality

Child Deaths Down, But Still Too Many: UNICEF

TARGET: Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate

PROGRESS: The global child mortality rate declined by almost one quarter between 1990 and 2006 [PDF] but the international community is not on target to achieve the goal, particularly in sub-Saharan Africa.

Under-five mortality rates in sub-Saharan Africa dropped from 187 per 1,000 live births in 1990 to 160 per 1,000 in 2006. The target for 2015 is 62.

Globally, it dropped from 93 to 72; the target is 31.

SIGNIFICANCE: 136 million babies are born every year [PDF, p.1]. Every drop in the global mortality figures of 1 death per 1,000 live births means some 136,000 fewer child deaths each year. The progress since 1990 (from 93 to 72) means nearly 3 million extra children born in 2001 saw their fifth birthday in 2006.

However, if current trends continue, 4.3 million child deaths will occur in 2015 alone that could have been averted [PDF] had MDG 4 been met

DEFINITION: The UNICEF reports below examine under-5 mortality (and other statistics). They use the term Under-5 Child Mortality (U5CM) to describe the probability of dying between birth and the exact age of five years. Others define child mortality more strictly as age 1-5 (i.e., excluding infant mortality).  However, in the discussion below, child mortality should be taken to mean U5CM. 

Malnutrition and Child Mortality

Malnutrition is by far the biggest contributor to child mortality, present in half of all cases, says the World Health Organisation (Economist, 24/1/08):

'(I)f the research is right, money for improving nutrition would be the most effective sort of aid around. At the moment, roughly $300m of aid goes to basic nutrition each year, less than $2 for each child below two in the 20 worst affected countries. In contrast, HIV/AIDS, which causes fewer deaths than child malnutrition, received $2.2 billion—$67 per person with HIV in all countries (including rich ones).

'Focusing on nutrition and mortality also makes sense, says April Harding of the Centre for Global Development, a Washington-based think-tank, because it forces policymakers to pay attention to health-care systems as a whole, rather than trying to save children “one disease at a time”. Given the scale of the crisis, the case for aid organisations redirecting money and attention to the problem of hunger looks compelling.'

Maternal and child undernutrition series launched in the Lancet (19/1/08)

UNICEF: The State of the World’s Children 2008

Congo is one of 11 countries where 20% of children die before the age of five, according to a UNICEF report released yesterday (Guardian, 23/1/08). A child born in Sierra Leone has the lowest chance of surviving until the age of five. The report, the State of the World’s Children, says nearly 9.7 million children under five died worldwide last year from disease or lack of food.

The report shows that progress has been made when 2006 is compared with 1990. Connect-World has examined a shorter time period and compared the 2006 data [PDF] with 1997 figures [PDF] (from The State of the World’s Children 1999, p.93) and has uncovered some new results below.

In 1997, 13 countries had an under five mortality rate of 20% or more [Tables 1, 2 below].Ten of those countries have seen improvements since then. Malawi experienced a 44% drop in mortality from 215 to 120 deaths per thousand (mortality was static in the other three countries) [Table 1 below].

Eight of the 10 most populous countries in the world -- accounting for over half of earth’s population -- saw reductions in mortality of between 29% (Pakistan) and 55% (Brazil) [Table 3 below].

Many countries have seen very large improvements. Mortality in Mongolia dropped by over 70% (from 150 to 43 per 1000) [Table 5 below]. In Iraq, it fell by 62% - equivalent to 71,000 fewer deaths in 2006 despite the ongoing conflict.

However, a number of countries have witnessed a considerable deterioration since 1997, notably Botswana and Swaziland, and including Kenya, North Korea and Zimbabwe [Table 4 below].

Taking a longer time period, the global mortality rate has declined by almost a quarter since 1990. Yet, global progress in reducing child mortality is insufficient to reach the fourth millennium development goal (MDG 4).

West and Central Africa are furthest from achieving the goal: the 2008 report says "no progress" has been made. This seems a little unfair when mortality per 1000 live births has fallen there by 22 since 1990. It is a small percentage (11%) compared with many other regions but it is comparable in absolute terms to the drop of 26 in, for example, "on track" East Asia and the Pacific (a region which includes China).

If current trends continue, 4.3 million child deaths will occur in 2015 alone that could have been averted had MDG 4 been met.

Most of the kids who died last year before the age of five could have lived if their parents had unhindered access to proper medical care (OneWorld, 22/1/08).

Table 1: Progress in countries where one in five children died before their fifth birthday in 1997*
	Under-5 mortality/1000
Country	1997	2006	change	% change
Niger	320	253	-67	-21%
Sierra Leone	316	270	-46	-15%
Angola	292	260	-32	-11%
Afghanistan	257	257	0	0%
Mali	239	217	-22	-9%
Liberia	235	235	0	0%
Guinea-Bissau	220	200	-20	-9%
Malawi	215	120	-95	-44%
Somalia	211	145	-66	-31%
Mozambique	208	138	-70	-34%
Congo, Dem. Rep.	207	205	-2	-1%
Zambia	202	182	-20	-10%
Guinea	201	161	-40	-20%
Average	240	203	-37	-15%

Table 2: Prevalence of high under-five child mortality rates (U5CM)*
	No. of countries
U5CM per 1000 live births	1997	2006
300 or more	2	0
200 or more	13	11
100 or more	49	41
50 or more	77	67

Table 3: Under-five mortality in the world's most populous countries*,† Under-5 mortality/1000 Rank Country Pop. (m) % of total 1997 2006 change % change World 6,671 100.0% 1 China 1,323 19.8% 47 24 -23 -49% 2 India 1,128 17.0% 108 76 -32 -30% 3 US 303 4.6% 8 8 0 0% 4 Indonesia 232 3.5% 68 34 -34 -50% 5 Brazil 186 2.8% 44 20 -24 -55% 6 Pakistan 162 2.4% 136 97 -39 -29% 7 Bangladesh 159 2.4% 109 69 -40 -37% 8 Nigeria 148 2.2% 187 191 4 2% 9 Russia 142 2.1% 25 16 -9 -36% 10 Japan 128 1.9% 6 4 -2 -33% Table 4: Selected countries where under-five mortality rose between 1997 and 2006* Under-5 mortality/1000 Country 1997 2006 change % change Botswana 49 124 75 153% Swaziland 94 164 70 74% Cameroon 99 149 50 51% Solomon Islands 28 73 45 161% Azerbaijan 45 88 43 96% Burkina Faso 169 204 35 21% Equatorial Guinea 172 206 34 20% Kenya 87 121 34 39% Gambia 87 113 26 30% Zimbabwe 80 105 25 31% North Korea 30 55 25 83% Trinidad & Tobago 17 38 21 124% Micronesia 24 41 17 71% Table 5: Selected countries where under-five mortality fell between 1997 and 2006*
	Under-5 mortality/1000
Country	1997	2006	change	% change
Mongolia	150	43	-107	-71%
Malawi	215	120	-95	-44%
Cambodia	167	82	-85	-51%
Iraq	122	46	-76	-62%
Niger	320	253	-67	-21%
Somalia	211	145	-66	-31%
Egypt	73	35	-38	-52%
Indonesia	68	34	-34	-50%
Brazil	44	20	-24	-55%
Syria	33	14	-19	-58%
Latvia	20	9	-11	-55%
Estonia	14	7	-7	-50%
Cyprus	9	4	-5	-56%
Greece	8	4	-4	-50%
Ireland	7	5	-2	-29%

Sources:
* 2006 child mortality data [PDF] (UNICEF); 1997 child mortality data [PDF] (UNICEF, p.93)
† List of countries by population (Wikipedia, with links to official sources; Jan 2008)

IRAQ: Child deaths down by 62% or 71,000 lives

Under-5 mortality in Iraq fell by 62% between 1997 and 2006 according to UNICEF figures [Table 5]. This equates to 71,000 lives. Sanctions were a likely factor behind both the high child mortality in 1997 of 122 per 1000 (it was 53 per 1000 in 1990) and the subsequent reduction to 46 per 1000 (4.6%) in 2006. In the absence of war, Saddam or sanctions, child deaths would probably have been fewer still. As we have seen above, mortality rates have been falling worldwide since 1990.

At 1997 child mortality rates, 114,000 deaths would have been recorded in 2006. The actual figure was 43,000. The number of births was up by 156,000 to 937,000 in 2006 but the number of under-5 deaths was down by 52,000 to 43,000 - less than half the 95,000 deaths recorded in 1997 (2006 birth and child mortality data [PDF], UNICEF; 1997 birth and child mortality data [PDF], UNICEF, p.95).

The apparent drop in mortalilty occurred despite the continuing conflict: according to Iraq Body Count, more civilian deaths from violence were recorded in 2006 than any other year since the invasion.

THE WAR AND SANCTIONS:

Some progress in the health of Iraqi children appeared to have occured by 2002, at which point acute malnutrition had dropped dramatically. Also, some aspects of child welfare - such as psychological well-being - may have deteriorated since 2003. A new report from Medact [PDF] found that the "war and its aftermath continue to have a disastrous impact on the physical and mental health of the Iraqi people" (Medact, January 2008). Long-term effects of the war globally and on the region remain to be seen.

Had Saddam stayed in power, a civil war may have been postponed rather than avoided. The risk was high because despite Iraq's apparently secular nature, power was divided along sectarian lines, with the minority Sunni Baath party dominant. The situation was unsustainable, and any transfer of power to the Shia majority ran the risk of generating fear and resistance among the Sunnis, even if they had nothing to do with the Baath party. (It was a risk that could have been foreseen by the Pentagon in 2003 before it combined rapid de-Baathification with a push for early elections).

Saddam’s removal in 2003, coupled with what turned out to be a failure to find an active WMD program eliminated the rationale for the sanctions. While the search for WMD was ongoing, most sanctions were ended on May 22, 2003 in UN resolution 1483. (Iraq had not first been certified by UN arms inspectors to be free of WMD as some had thought necessary, TIME, 17/4/03.)

Prior to the invasion, the Director of the Foreign Policy Centre, a think tank launched under Tony Blair's patronage, argued that "the collateral damage of a decade of containment: comprehensive economic sanctions, no-fly zones, periodic military attacks" would continue as long as Saddam remained in power (Observer, 11/08/02). Blair also made a link between sanctions and regime change: "If you had a different regime in Iraq that was in obedience with the UN position, then everything could be resolved, including sanctions, which is exactly why for the Iraqi people the best thing that could possibly happen is to see the back of Saddam" (10 Downing St, 11/1/03).

OTHER SURVEYS:

There have been a number of other studies which cast doubt on the statistical findings above and may highlight the difficulty of obtaining accurate publc health statistics, particularly during a conflict.

1. The State of the World’s Children 2007. In last year's report, a figure was given for Iraqi under-5 child mortality in 2005 of 125 per 1000. As it is unlikely mortality could have dropped so much between 2005 and 2006, there are two strong possibilites: 1) One or both of the 2005 and 2006 figures are very inaccurate. 2) The 2005 figure is from a study that took place several years earlier and was the most recent available in 2005 (i.e., the time frame is inaccurate but the drop may be real). NOTE: The latter possibility may be behind some of the other results in this document.

Results from the 2007 report have been repeated in other publications such as State of the World’s Mothers 2007 - the main finding of that report on Iraq (informed by UNICEF fgures) were interpreted in the Medact Report on Iraq as "Death rates of children under five sliding towards those of sub-Saharan Africa" (p.2; see below).

2. Multiple Indicator Cluster Survey 2006 (MICS3) by COSIT, Ministry of Planning and Development Cooperation, Iraq (who also collaborated on the The Iraq Family Health Survey 2006/7 below). It found under-5 mortality to be 41 per 1000 in the 5-year period preceding the survey, i.e., c. 2002-6 (p.32).

3. The Iraq Family Health Survey 2006/7 found results on a similar scale but went back to 1993. "Indirect" child and infant mortality went up from 2003 to 2005. In 2005, indirect under-5 child mortality was 59 per 1000, the same as in 1996 (Table 25). The deterioration since the invasion is part of their wider finding of 151,000 violent deaths in Iraq from March 2003 through June 2006 (N Engl J Med, 9/1/08).

The study shows a steady drop in child mortality from 1993 to 2001. The 1993 estimate was higher than 1990 UNICEF data, however, none of the figures in the period studied were anywhere near the 122 per 1000 in 1997 that UNICEF reported (see above). This would appear to flatly contradict the 1997 UNICEF data and, if true, to undermine the claimed link between sanctions and the deaths of hundreds of thousands (PBS, November 02). Part of the problem may be methodological: according to the survey report: "these estimates are rough averages... the children will have been born over a wide time interval and died over a wide range of ages. Thus the indirect estimates cannot be expected to pick any sudden upsurge or sharp drop in mortality" (p.29). This would suggest that the usefulness of the survey's mortality data for examining changes over time may be limited.

4. The 2008 Medact report, rehabilitation under fire: health care in Iraq 2003-7 said that problems with mortality data need to be addressed: "Health information has become more rather than less political, and there is an urgent need to strengthen the national health information system, and to assess civilian mortality rates throughout the conflict in a well-resourced, independent study" (p.9).

5. Report of The In Depth Analysis Iraq Child and Maternal Mortality Survey / 1999. Under-five mortality rates decreased from (87.8 / 1000 live births) in the second half of the seventies to reach a low of (58.9) in the second half of the eighties, then to rise again in the first and second half of the nineties to (91.0 and 121.7 respectively). Neonatal, postnatal, and child (1-5) deaths doubed in a 10-year period (pp.57-8, Table 4.1).

Bottom line:
Mortality statistics may be more accurate at tracking global changes than country-specific changes. Further investigation is needed before the possibilities can be ruled out that the effect of sanctions was exaggerated or that there has been a recent huge reduction in child mortality despite the war. (It remains possible that neither is true, e.g. that there was a large improvement in the first few years of the decade - after sanctions were modified - that was not fully reversed after 2003.)

United States: Up to 20,000 unnecessary child deaths in 2006

Millions of unnecessary child deaths occur every year. Most occur in developing countries and are cheap and easy to prevent. Some occur in richer economies. Connect-World has found that up to 20,000 may occur in the US.

In 1997, the US and Greece had the same child mortality rates: 8 per 1000. In 2006, that of Greece had halved while it stayed constant in the US even though it has over twice Greece's 2006 income per capita. In 2006, 34,000 children under 5 died in the US. If progress had kept pace with Greece, 17,000 lives would have been saved in 2006 alone. If, instead, the US was able to match the top performers such as Sweden (where it is 3 per 1000) [PDF], over 20,000 lives would be saved every year (2006 birth and child mortality data [PDF], UNICEF; 1997 birth and child mortality data [PDF], UNICEF, p.97).

It is notable that child (under-5) and infant (under-1) are identical in some countries though not the US, indicating that mortality among those aged 1-5 is higher in the US than in several industrialised countries.

Some observers might say charity begins at home and these statistics provide a reason for cutting back on US foreign aid. In fact, cutting back on America's small aid budget - which is much lower per head than that of Sweden - would do little to improve US health care. America lags behind other wealthy countries in the overall performance of its medical system (Economist, 14/01/08; see also) despite spending far more per head than any other rich country (OECD, 2007). Perhaps 100,000 lives a year are preventable in the 0-75 age group if the US could catch up with the best performers (Economist, 10/01/08).

RESOURCES:

MDG Monitor with Map (UN)

The State of the World’s Children 2008 (UNICEF, 2008)

UN Millennium Development Goals (UN) see also United Nations site for the MDG Indicators (UN)

The Millennium Development Goals Report 2007 [PDF, p.14] (UN, 2007)

4: Reduce child mortality (World Bank)

Facts and figures from The World Health Report 2005 (WHO, 2005)

Quick Facts [PDF] (WHO, 2005)