MEDICINE
REVIEW ARTICLE
Mortality in Children Under 5 Years
and Social Situation: International
Comparison
Oliver Razum, Jürgen Breckenkamp
SUMMARY
Introduction: Every year, 10.6 million children under 5 years die world-wide. International
comparisons of under 5 mortality (U5M) rates, trends, and causes of death in children are
an indicator of social progress and inequalities within and between societies. Methods: Using
WHO data the authors compared the magnitude, trends and causes of U5M between nations in
relation to total per-capita health expenditure and geographic region. They also reviewed selected
literature on causes and trends of infant/child mortality. Results: Most U5M occurs in developing
countries. Underlying causes include diarrhea, pneumonia, malnutrition, neonatal conditions
and in Sub-Saharan Africa, malaria and AIDS. Low per-capita health expenditure is not a sufficient
cause of high U5M; economic/political instability, however, is a strong determinant. Discussion:
One of the Millennium Development Goals is to decrease U5M by two-thirds by the year 2015; it
will probably not be reached in Sub-Saharan Africa. U5M is preventable by simple, low-cost
interventions, so differentials in U5M do not constitute geographic or climatic inequalities, but
are socioeconomically and politically determined.
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Key words: under 5 mortality, developing countries, Germany, poverty and human development,
Millennium Development Goals
H
ealth is considered a social good to which all people have the right, regardless of
their geographical and socioeconomic situation. In addition, health is a form of
human capital which serves all people, contributing to economic development and social
stability (1). At the same time, ease of travel and increasing numbers of travelers mean that
many health problems are no longer locally contained. An example is the rapid spread of
infectious diseases such as SARS.
Health and disease nevertheless remain unequally distributed. Nowhere is this so clearly
exemplified as in childhood mortality. Each year, 10.6 million children under 5 die worldwide. Many of these deaths are preventable (2). Hence child mortality constitutes an
indicator for differences in social and health development between countries on the one
hand, and for inequalities within individual societies on the other. International comparison
of levels of child mortality, its time trends and underlying causes of death point both to social
development and to persistent inequalities in and between societies. They also form a basis
for developing strategies aimed at reducing child mortality (2–4).
The majority of child deaths take place in the resource-poor countries of the South, usually
referred to as "developing countries" (table 1). This might lead to the assumption that it is
tropical diseases that are primarily responsible for the high child mortality rates. The
authors show in the following analysis that the geography and disease patterns often
represent just a small part of the difference in child mortality between different countries.
A lack of access to sophisticated modern medicine also plays a relatively small role. The key
factors are absolute poverty and "damaged social conditions across whole regions" (5).
Together these factors lead to inadequate access to simple, cheap and highly effective
measures such as oral rehydration therapy in diarrheal illness or antibiotics in pneumonia.
Disease is, in the words of the English physician and epidemiologist Geoffrey Rose
(1926–93), primarily socially and economically determined (6).
Abteilung Epidemiologie & International Public Health, Fakultät für Gesundheitswissenschaften, Universität Bielefeld: Prof. Dr.
med. Razum, Dr. Breckenkamp
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TABLE 1
The 10 countries with the highest number of child deaths under 5 years and the highest mortality rate
in 2004
Ranking by number of child deaths
under 5 years
Country
Number
of
child deaths
Ranking by
mortality rate
Ranking by number of child deaths under
5 per 1000 live births (mortality rate)
Country
Mortalitiy rate
India
2 204 000
44
Sierra Leone
283
Nigeria
Ranking by
number of
child deaths
27
1 059 000
9
Angola
260
9
Democratic
Republic of Congo
589 000
5
Niger
259
10
China
537 000
74
Mali
219
13
Ethiopia
515 000
16
Democratic
Republic of Congo
205
3
Pakistan
482 000
39
Equatorial Guinea
204
77
Bangladesch
289 000
47
Guinea-Bissau
203
57
Uganda
203 000
24
Chad
200
20
Angola
199 000
2
Nigeria
197
2
Niger
194 000
3
Ivory Coast
194
14
Sources: World Health Statistics 2006 and http://www.who.int/reproductive-health/global_monitoring/RHRxmls/RHRmainpage.htm
(Accessed 11 September 2007)
Methods
The authors compared the level and causes of child mortality, that is, death before completion
of the fifth year of life per 1 000 live births per year, between nations, dependent on
per-capita expenditure on health and geographical location. A secondary analysis including
World Health Organization (WHO) health and social data was conducted. The necessary
data were available for 164 of 192 WHO member states (for data sources see box 1; for
additional methodological detail see supplement "Methods" at the end of this article).
The authors set the current situation in poorer countries against the development over
time in Germany. Historic data allow estimation of possible decrease in mortality even
without effective biomedical interventions; the current data offer a comparison of the extent
of inequality in mortality within a rich society. Because long historic time series for child
mortality are almost impossible to reconstruct (7), the authors used the literature and the
database of the Federal Statistical Office (Statistisches Bundesamt) (box 1) to derive time
series for infant mortality, in other words, death before completion of the first year per 1000
live births per year.
Medline searches and searches of the websites of relevant international organizations
were carried out to collate data on reductions in child mortality (see supplement "Methods").
Results
Historic trends in infant mortality in Germany
Infant mortality in Germany in the 19th century was at around the same level as that of
many Sub-Saharan African countries today. Diarrheal illnesses were a common cause of
death. Infants who were not breast fed or not breast fed for long enough because their
mothers were malnourished were at particular risk of infection. Infant mortality was
significantly higher in poor than in wealthy areas, and higher in working class families than
in bourgeois families (7–10). Diagram 1 shows the time trend in infant mortality.
The fall in mortality predated the development of effective biomedical treatments such
as antibiotics. Key factors, in addition to improved hygiene, and breast feeding in particular,
were maternity leave, increasing wealth, and the rise of pediatrics (7–11). Infant mortality
in Germany today is extremely low compared to that of developing countries, at just
4.1/1000 in the year 2004 (12). Despite wealth and the wide accessibility of high quality
health care, however, there is evidence of social inequality. Hence infant mortality in the
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BOX 1
Data sources and useful references
International data on child mortality and on social and
economic indicators on the WHO website:
www.who.int/whosis/en/
www.who.int/whosis/whostat2006/en/
Results of surveys of social inequality and child
mortality from a large number of countries, stratified by
social indicators such as maternal education and
household income, at:
www.who.int/whosis/database/core/core_select_
process.cfm?countries=all&indicators=child_mort
Interactive maps and diagrams in "Gap-Minder" at:
www.tools.google.com/gapminder/
Wide ranging material on the UNICEF’s and WHO's
"Integrated Management of Childhood Illness"
initiative, at:
www.who.int/child-adolescent-health/integr.htm
Information on progress in meeting the "Millennium
Development Goals" on the web pages of the United
Nations (UN) and the Federal Ministry for Economic
Cooperatioon and Development (Bundesministerium
für wirtschaftliche Zusammenarbeit und Entwicklung,
BMZ):
www.un.org/millenniumgoals/
www.bmz.de/de/themen/MDG/Entwicklung/
dokument04/index.html
Databases of the Federal Statistical Office
(Statistisches Bundesamt) at:
www.destatis.de/
German language introduction to international public
health with reference to child mortality at:
Razum O, Zeeb H, Laaser U (Hrsg.): Globalisierung –
Gerechtigkeit – Gesundheit. Einführung in International
Public Health. Bern: Huber 2006
federal State of North Rhine Westphalia for the year 2004 was 5.0/1000, compared with
3.4/1000 in Baden-Württemberg and Bavaria. Within North Rhine Westphalia itself,
mortality ranged from 3.3/1000 in the Rhein-Sieg-Kreis area, up to 8.7/1000 in Gelsenkirchen.
Infants with non-German nationality in North Rhine Westphalia had a mortality rate of
11.1/1000 in 2004, compared with 4.6/1000 for German infants (12).
Contemporary child mortality and social status in international comparison
Table 1 shows clearly that child mortality particularly affects poorer countries. The
relationship between social development, measured as total per-capita health expenditure is
shown in diagram 2. The mean line for child mortality (CM) and health expenditure (HE)
divide the coordinates into four quadrants (a–d). All countries with a level of child
mortality above mean (CM) are found in quadrant a, while their levels of per-capita health
expenditure lie consistently below the mean HE. The 20 countries with the highest infant
mortality are found in Sub-Saharan Africa. If all 192 WHO member states are taken as the
base, Afghanistan is the only non-African country in this group (13). Many of these
countries are characterized by political or economic instability (13).
However, it is by no means automatic that low per-capita health expenditure leads to
higher child mortality. In quadrant c are countries whose health expenditure lies significantly
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DIAGRAM 1
Infant mortality in Germany 1870–2006. Source: data from Diesfeld 2006 (8), Spree 1981 (9),
Ehmer 2004 (7), Hanauer 1929 (10), Federal Statistical Office (Statistisches Bundesamt
1946–2006). Curve shape interpolated (see supplement "Methods")
DIAGRAM 2
Total per-capita health expenditure (2003) and child mortality (2004). USD, US dollar.
Source: WHO data (22)
below the mean, but whose child mortality is low. Sri Lanka has a 15 fold lower child
mortality than Equatorial Guinea (14/1000 versus 204/1000), despite lower per-capita
health expenditure, at 121 US dollars (Equatorial Guinea :179 US dollars). The other three
countries in quadrant a, whose child mortality is high relative to their per-capita health
expenditure, are those African countries especially affected by AIDS – Swaziland, Botswana
and South Africa (13).
Quadrant d contains countries with high health expenditure upwards of around
1500 US dollars per capita per year, the variation in child mortality is relatively small. In
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other words, a marginal increase in health expenditure leads to barely any further reduction
in child mortality. The USA spends around three times as much per capita per year on health
as Slovenia, (5711 versus 1669 US dollars), but has higher child mortality (8/1000 versus
4/1000). A trend towards a reduction in child mortality with increased per-capita spending
on health is only found in the lower part of quadrant a and in quadrant c.
Child mortality varies not only between but within countries. There was for example a
factor of 7 difference in child mortality between the two Indian states of Madhya Pradesh
and Kerala in 1999 (138/1000 versus 19/1000) (2). Surveys from 60 countries also show
that children from poorer households have a significantly higher risk of death than children
from wealthier households (13, 14). In addition, the gap within countries appears to be
widening (15).
Causes of child mortality
The commonest causes of death both in richer and poorer countries are perinatal complications.
In poorer countries neonatal sepsis and asphyxia play a key role in addition to prematurity.
Pneumonia and diarrheal illnesses are the most common causes of death in the post neonatal
period, in more than half of cases, in association with malnutrition. AIDS and malaria also
contribute significantly to child mortality in Sub-Saharan Africa (2–5, 16). Table 2 shows
the distribution of causes of death for the 6 WHO regions.
In Germany, child mortality is dominated by neonatal mortality, which is in turn
dominated by early neonatal mortality (0–6 days). In North Rhine Westphalia, half of all
neonatal deaths in 2004 occurred in the first six days of life, and the majority were related
to perinatal causes and congenital malformations (12).
Tackling child mortality in developing countries
Child mortality fell in developed countries long before the introduction of effective medical
interventions (diagram 1). Key factors were growing wealth, but particularly an increase in
breast feeding, as well as social and public health advice and initiatives, and, increasingly,
the development of pediatrics (5, 8, 9, 11). The availability of vaccination and antibiotics
further improved the situation. Child mortality fell between 1970 und 2004 from 27/1000
to 6/1000 – a fall of 78%. The survival of premature infants thanks to effective but expensive
(17) obstetric and perinatal medicine played a growing part in this trend.
Economic growth and wealth remain far lower in developing countries (11). Nevertheless,
simple and affordable interventions exist for many determinants of child mortality. David
TABLE 2
Child deaths and mortality rates and percentage distribution of causes of death for the 6 WHO regions,
annual mean, 2000–2003
Africa
Southeast Asia
East
Mediterranean
Western
Pacific
America
Europe
4.4
million
3.1
million
1.4
million
1.0
million
0.4
million
0.3
million
Mortality rate
per 1000 live births*
171
78
92
36
25
23
Perinatal complications
26%
44%
43%
47%
44%
44%
Pneumonia
21%
19%
21%
13%
12%
12%
Diarrhea
16%
18%
17%
17%
12%
13%
Malaria
18%
0%
3%
0%
0%
0%
Deaths under 5 per year
Measles
5%
3%
4%
1%
0%
1%
HIV/AIDS
6%
1%
0%
0%
1%
0%
Accidents
2%
2%
3%
7%
5%
7%
Other
5%
12%
9%
13%
25%
23%
Source: modified from Bryce et al. 2005 (4)
* Reference year 2003. Source: whostat2005_mortality.xls (Accessed 11 September 2007)
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BOX 2
Millennium Development Goals –
MDGs
Goal 1:
Eradicate extreme poverty and hunger
Goal 2:
Achieve universal primary education
Goal 3:
Promote gender equality and empower women
Goal 4:
Reduce child mortality
Target: Reduction of mortality in under 5s by two thirds
between 1990 and 2015
Goal 5:
Improve maternal health
Goal 6:
Combat HIV/AIDS, malaria, and other diseases
Goal 7:
Ensure environmental sustainability
Goal 8:
Develop a global partnership for development
Source: UNICEF 2005 (13); BMZ 2005 (20)
Morley showed as long ago as the 1960s that "Under-Five-Clinics" contributed to a stark
decline in mortality. They comprised, based on experience gained in developed countries,
weight monitoring, advice on hygiene and nutrition, preventive antimalarial medication,
vaccination, and simple treatment for pneumonia and diarrhea (5). The management of
diarrhea was revolutionized by the recognition that fluid and electrolyte resorption occurs
more effectively in the presence of glucose. Hence mothers in developing countries can
effectively prevent dehydration and death by administering sugar-salt solution (18).
Based on the experience that the determinants of child mortality are not merely medical,
broader approaches to health care were developed, in particular the notion of "Primary
Health Care" in 1978. The concept had not been universally implemented due to lack of
political will, but some elements of it have been introduced (8). Hence we find in UNICEF’s
and the WHO's "Integrated Management of Childhood Illness" initiative not only strategies
for promoting competency in health personnel. There is also a focus on the improvement of
the health system and the health behaviour of families (box 1). It is frequently the case that
the wealthy are more readily reached by these initiatives than the poor, which leads to a
widening of the gap within a society (15, 19).
In the least developed countries, progress has been slow. Hence child mortality fell by just
36% between 1970 and 2004 (from 244/1000 to 155/1000) (13). While there has been a marked
fall in Bangladesh, for example, there has actually been an increase since 1990 in politically and
economically unstable countries of Sub-Saharan Africa, such as Angola or countries with a high
prevalence of HIV, such as South Africa (14). It was in this context in 2000 that the plenary
session of the United Nations proclaimed its "Millennium Development Goals" (boxes 1 and 2).
According to these, child mortality is to be reduced by two thirds by 2015 (13, 20).
This goal is unlikely to be achieved in Sub-Saharan Africa and in South Asia, in other
words, the regions with the highest child mortality (table 1). Diagram 3 shows the falling
trends in child mortality since 1990 and the 2015 goal for various regions. The area between
the red lines represents the size of the deficit between planning and reality. Latin America
and East Asia, on the other hand, are on the way to meeting these targets.
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DIAGRAM 3
Achievement of the Millenium Development Goal 4 in various regions, 1990–2015.
Source: data from UNICEF 2005 (13).
Discussion
Deaths in children under 5 are largely avoidable; effective measures are available. Despite
this, the risk of death for children is very unevenly distributed across the world. There is a
factor of up to 70 difference, for example between Sierra Leone and Sweden. This is
significantly higher than the factor of 54 by which child mortality fell in Germany between
1870 and 2004, despite the unavailability of many key interventions in the 19th century (8).
There are also massive differences in per-capital health expenditure, with a factor of as
large as 408 difference between the Democratic Republic of Congo and the USA. Lower
health expenditure does not automatically lead to high child mortality, however, and
appropriate investment in health lead to a reduction, as has been shown in several countries
(13, 14). Conversely, high health expenditure does not guarantee equity within a society.
The example of child mortality in Germany shows that not all individuals are able to
benefit equally even from effective and financially accessible health care.
Although there is a clear link between child mortality and geographical region (most
pronounced in Sub-Saharan Africa), it is, with the exception of malaria, not tropical diseases
but "diseases of poverty" which account for the difference – just as in Germany 100 years
ago (2, 8). AIDS-related deaths add to this. In many countries, such as Sierra Leone and
Afghanistan, political and economic instability, which damage public health and social
structures, further increase child mortality (13, 21).
The historical and international analysis of social status and child mortality is based on
available WHO data from 164 of the 192 member states (22). It should be noted that "health
expenditure" has no standard international definition, however, and that data are missing
for 28 countries. In interpreting the results it should also be remembered that 82 of the 192
countries lack complete cause of death statistics. Poor countries in particular work on the
basis of sub-samples, which delivers incomplete data (14, 22). It is therefore possible that the
highest child mortality rates in particular are still underestimates.
Even those countries with almost complete death registration mostly record cause of
death in a monocausal way, which interferes with the analysis of causes of death in children
(2, 3). In poorer countries, illnesses often occur sequentially or concurrently. Hence for
example 50 to 80% of children suffering from measles suffer from both pneumonia and
diarrhea concurrently (16).
Despite these limitations, the data still permit an analysis of trends. They suggest that
there is still a lack of political will to view high child mortality in the world's poor countries
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as inequitable, and to take decisive action (8, 11). Although the current G8 summit explicitly
mentioned child mortality in Africa, most G8 countries give less than the long pledged
0.7% of gross domestic product (GDP) for development aid (Germany 2003 0.28%, 2006
a predicted 0.36%) (20, 23). In essence, the same argument is valid – albeit in attenuated
form – in relation to deaths in children from socially disadvantaged groups within Germany.
The point of departure for developing countries today is different from that of Germany
at the end of the 19th century (8, 11). Whereas social hygiene contributed majorly to the
great success in reducing child mortality in those days, a more interdisciplinary and
multiprofessional approach is needed today. This would include, for example, the improvement
of health care systems in developing countries as well as the creation of sustainable
financing mechanisms (11, 24). Social and political institutions play a key role, for example
in the development of strategies aimed at reducing poverty and recognizing health as a
public good (1, 25). In parallel, measures to promote economic growth, strengthen education
and women's rights, and support stable government in developing countries are needed
(11, 21, 23). New biomedical interventions such as oral rotavirus immunization can save
lives, but must be made affordable and equitably accessible across social classes. To finish
with a word from Geoffrey Rose: Not only is disease economically and socially determined
– the remedies must also be economic and social (6).
Dedicated to Prof. H. J. Diesfeld on the occasion of his 75th birthday
Conflict of Interest Statement
The authors declare no conflict of interest in the terms of the guidelines of the International Committee of Medical Journal Editors.
Manuscript submitted on 24 Juy 2007; final version accepted on 17 September 2007.
Translated from the original German by Dr. Sandra Goldbeck-Wood.
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Corresponding author
Prof. Dr. med. Oliver Razum
Abteilung Epidemiologie & International Public Health
Fakultät für Gesundheitswissenschaften, Universität Bielefeld
Postfach 100131
33501 Bielefeld, Germany
[email protected]
SEE NEXT PAGE FOR ADDITIONAL MATERIAL
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SUPPLEMENT
Mortality in Children Under 5
Years and Social Situation:
International Comparison
Oliver Razum, Jürgen Breckenkamp
Methods
The magnitude and causes of child mortality were examined in relation to total
per-capita health expenditure, measured in international US dollar rate, and in
relation to geographical region, by means of a secondary analysis of World Health
Organization (WHO) data (www.who.int/whosis/whostat2006/en/). The data required
for the analysis were available for 164 of the 192 member states; health data were
missing for 28 states.
Per-capita health expenditure was a better reflector of a society's expenditure on
health than was gross domestic product (GDP). In the sample of 164 countries,
however, this correlated strongly with GDP (Spearman correlation coefficient
0.965, p < 0.0001).
One methodological weakness is the difficulty in making international comparisons
of per-capita health expenditure. However, the likely underestimate of this in
developed countries would not substantially alter the interpretation of the results.
Similarly, per-capita health expenditure for a given country represents a mean
across all social groups, and therefore conceals differences within a country. This is
an inevitable problem with all international comparisons.
Included in "child mortality" were all deaths before completion of the fifth year of
life, per 1000 live births within each country during 2004. The geographical region
was determined by WHO region. These data were entered into SAS software and
represented as scatter plot. A regression analysis showed an approximately log
linear association between child mortality and total per-capita health expenditure.
Because of the difficulty of interpreting logarithmic data, linear axes are used and a
curve, derived using a spline-interpolation, is displayed. Straight lines indicating the
mean child mortality and per-capita expenditure rates were then drawn through the
coordinate system.
For table 1 ("The 10 countries with the highest number of child deaths under 5 years
and the highest mortality rates, 2004"), the number of deaths was estimated as indicated
by Black et al. (2003) via multiplication of the number of live births (2005) with the
mortality rate in under 5s (2004). Of the 164 states upon which the remaining analyses
in this article are based, 14 had to be excluded due to missing data for live births. The
ranking of countries by child deaths per 1000 live births is, however, not affected by
this. Sources were: World Health Statistics 2006 and www.who.int/reproductivehealth/global_monitoring/RHRxmls/RHRmainpage.htm.
Diagram 3 ("Achievement of Millenium Development Goal 4 in various regions,
1990–2015") was constructed using current data, as indicated by Haines A, Cassels
A: Can the Millenium development goals be attained? BMJ 2004; 329: 394–7.
Results of surveys of social inequality and child mortality from a large number
of countries, stratified by social indicators such as maternal education and household
income, can be found in a WHO database (box 1).
These data are largely derived from so-called Demographic and Health Surveys
(DHS). An overview of the 185 Demographic and Health Surveys can be found at
www.measuredhs.com/aboutsurveys/search/search_survey_main.cfm?SrvyTp=type
&listtypes=1
Dtsch Arztebl 2007; 104(43): A 2950–6 ⏐ www.aerzteblatt.de
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MEDICINE
Secular trends for child mortality in Germany are almost impossible to
reconstruct due to missing data. For this reason, literature sources (for individual
years in the time interval 1870–1945) and the database of the Federal Statistical Office
(Statistisches Bundesamt) were used (complete from 1946–2006) to construct a time
series for infant mortality. Infant mortality was defined as: death before completion
of the first year of life per 1000 live births per year. For the time before 1910 values
pertaining to large regions such as Prussia were used. Some of the relevant data points
quote two or three year means. In order to present trends in mortality accessibly
despite missing data for individual years, a curve was interpolated using a parametric
cubic spline. Because of the variation in accuracy and completeness of the data, this
figure can only reliably indicate trends.
In Germany today, infant mortality accounts for 80% of all child mortality. But
because this rate is not stable across time and federal states, the magnitude of infant
mortality does not allow for precise conclusions about child mortality. In particular,
infant mortality does not reflect the growing proportion of accidents as a cause of
child mortality. Given the dimension of the fall (by a factor of 62 from 1870 to
2006), however, infant mortality is an adequate indicator of trends in child mortality.
The description of the strategies to combat child mortality is based on literature
searches carried out on Medline for 2005 and 2006. The following search terms and
synonyms derived from a thesaurus where appropriate, were used: "millennium
goals", "neonatal", "infant", "child", "mortality", "statistics", "health", "poor",
"survival", "deaths", "causes of death", "under nutrition/malnutrition".
In addition, the websites of the WHO, the United Nations, the World Bank,
World Resources Institute, USAID, and ministries (including BMZ) were searched
for strategy documents and data sources. For reasons of space, the results section of
this article contains references only to reviews and selected key publications on the
subject.
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