Where and why are 10 million children dying every year?

Abstract:

"More than 10 million children die each year, most from preventable causes and almost all in poor countries. Six countries account for 50% of worldwide deaths in children younger than 5 years, and 42 countries for 90%. The causes of death differ substantially from one country to another, highlighting the need to expand understanding of child health epidemiology at a country level rather than in geopolitical regions. Other key issues include the importance of undernutrition as an underlying cause of child deaths associated with infectious diseases, the effects of multiple concurrent illnesses, and recognition that pneumonia and diarrhoea remain the diseases that are most often associated with child deaths. A better understanding of child health epidemiology could contribute to more effective approaches to saving children's lives."

This article examines the reasons why children are dying, and recommends actions to be taken to prevent child mortality. Using data from the year 2000, the authors provide statistics in the form of maps, graphs, tables, and charts that focus on the following:

• Where do most child deaths occur? 41% of them occur in sub-Saharan Africa and 34% in south Asia. The former region has had the slowest mortality fall rate since 1970-1974. Despite a 50% drop in mortality in south Asia since that time, almost 1 in 10 children there dies before the age of 5 years. Most deaths in these countries occur in rural areas, although urban slum populations can have high rates as well. "Because there is substantial variation in death rates within these regions, planning for health interventions should take place at a national level. The incomplete and unreliable nature of these data in many countries can make this task difficult, so assessment of the needs and possible interventions for more homogeneous groups of countries is also worthwhile."
• Risk factors for child mortality include drinking unsafe water, insufficient water for hygiene, lack of access to sanitation, and non-exclusive breastfeeding between the ages of birth and 5 months. "Child deaths are commonly the result of several risk factors. In the future, the joint effects of two or more risk factors on each underlying or associated cause of death should be estimated together."
• The authors critique the strategy of stipulating (and recording) a single underlying cause of death, which is based on a desire to avoid allowing the sum of deaths from all causes to exceed the total number of child deaths. In low- and middle-income countries, children often become seriously ill with a number of diseases or infections before death. For example, "In children with vitamin A deficiency, the risk of dying from diarrhoea, measles, and malaria is increased by 20-24%. Likewise, zinc deficiency increases the risk of mortality from diarrhoea, pneumonia, and malaria by 13-21%...Correct classification of undernutrition and vitamin A and zinc deficiencies as underlying causes of death will permit a true estimate of the importance of these conditions and recognition that interventions can target both the nutritional condition and the resulting terminal infectious diseases."
• Clinical causes of death:
  
  • Classification - in the countries where 90% of child deaths take place, the authors claim, cause-of-death data is not adequately recorded. Because most child deaths are not medically attended, a strategy that includes data from surveys and interviews with family members might be an alternative to the reporting of vital events.
  • Neonatal disorders - "Of the 10.8 million deaths worldwide of children younger than 5 years, 3.9 million occur in the first 28 days of life...24% are caused by severe infections, 29% by birth asphyxia, 24% by complications of prematurity, and 7% by tetanus."
  • Distribution of causes of death globally - A prediction model was used to estimate the distribution of deaths for the 42 countries with 90% of all such deaths. The estimates include "22% of deaths attributed to diarrhoea (14-30%), 21% to pneumonia (14-24%), 9% to malaria (6-13%), 1% to measles (1-9%), 3% to AIDS, 33% to neonatal causes (29-36%), 9% to other causes, and fewer than 1% to unknown causes."
  • Comparison with WHO estimates - "both sets of estimates are generally consistent." Analysing any differences between the WHO model and the prediction model used in this article, the authors say, is important in evaluating the strengths and weaknesses of different data sources and methodologies; they provide a detailed comparison to this end.
  • Country typologies by major causes of death - "In the 42 countries we considered, the proportions of deaths caused by pneumonia and diarrhoea were fairly consistent, whereas the proportions for malaria, AIDS, and deaths in the neonatal period differed strikingly between countries." Various profiles are used to illustrate the way in which aggregate estimates of causes of death in a region like sub-Saharan Africa are misleading: some countries have very little AIDS and malaria while others are severely affected.
• Co-morbidity in child deaths - the authors point to synergy in causes of death and co-occurrence of infectious diseases as "an important public health problem".

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This paper is part of a 5-part series on child survival published by The Lancet. Click here to access an overview of that series.

Source:

Summarised and reprinted with permission from Elsevier (The Lancet, 2003, Vol No 361, pages 2226-34). Click here for the Lancet Home Page.