"There's some good news and then there's some bad news," said Helga Fogstad, the director of health for the United Nations Children's Fund, or UNICEF.
Her team helped produce a new report that marks a historic moment for child mortality numbers.
For the first time on record, the number of children worldwide who died before their 5th birthday has dipped below 5 million. In 2022, 4.9 million young children died – that's fewer than half the number who died in 2000. Some countries, including Malawi, Rwanda, Cambodia, Mongolia and Uzbekistan, have done even better, reducing their country's numbers by more than 75%.
"This is historic. This is very positive. However, on the discouraging side, we need to accelerate efforts," Fogstad said, noting that 4.9 million is a monumental number of deaths and these children primarily died from preventable and treatable conditions.
She says the progress that's been made is the result of many interventions, from vaccination efforts to improved nutrition and access to antibiotics.
"This has been done by governments and NGOs, donors, health-care professionals – and also families and individuals that have more knowledge today," Fogstad said, pointing to the U.N.'s Millennium Development Goals as a force that united people around the shared target of reducing childhood mortality.
However, she warns, there is a lot more work to do. A child's chance of surviving the first five years of life varies greatly depending on where they are born.
The latest data show families in sub-Saharan Africa and Southern Asia shoulder most of the burden. A child born in sub-Saharan Africa is, on average, 18 times more likely to die before turning 5 than a child born in Australia or New Zealand. And many of these deaths are caused by things like diarrhea, malaria and complications during birth, which can be addressed if people have timely access to medical care.
In addition to starkly different child mortality rates between countries, there are inequalities within some countries.
Li Liu, a professor at Johns Hopkins' Bloomberg School of Public Health, said she's seen this divide play out in Ethiopia. The country has dramatically reduced the number of kids who die before their 5th birthday – from 200 deaths per 1,000 births in 1990 to under 47 deaths per 1,000 births in 2021 – but the gains have been uneven.
"There's this huge gap between urban and rural areas. So, in urban areas, you see a lot faster decline in child mortality," Liu said. "A lot more resources are needed to try to scale up interventions in rural areas."
Other factors that correlate with a child's chance of dying include the family's wealth and the parents' education level.
In low- and middle-income countries where data was available, children born into the poorest households were more than twice as likely to die before the age of 5 compared to children born into the richest households. There's a similar pattern with parental education: In families where a mother had no education or only a primary-school education, the child was more than twice as likely to die before age 5 than a kid born to a mother with secondary or post-secondary education.
"We know that female education [for mothers] is one of the important things that can really improve child mortality," said Ole Frithjof Norheim, a physician and professor of global public health at the University of Bergen in Norway.
What has succeeded
One of the benefits of tracking each country's progress and gathering data on what is working is that "we know what is needed" to make more progress, said UNICEF's Fogstad.
She points to the use of community health workers in places like Malawi, Ethiopia, India and Iran as a particularly effective intervention. These workers, often women with some health-care training and roots in the communities, teach people about everything from washing hands to stave off infection to better nutrition and the use of bed nets to avoid malaria.
"They are also key in ensuring that these children get to the right services at the right time, so it doesn't become too late," said Fogstad.
But, she added, many of these community health workers need more training and need to be better compensated. "In many countries, they are actually unpaid," she said.
What still needs work
Of the 4.9 million children who died before their fifth birthday in 2022, 2.3 million were newborns who passed away in the first month of their life. The number of deaths among newborns has not fallen as quickly as it has among older age groups.
"It's important to focus on this age group because there are affordable, creative, innovative interventions," said Liu, who served on a technical advisory group for the UN report.
"For example, there's kangaroo mother care. For premature babies, you put them on your bare skin and that could actually help regulate the body temperature of the babies and also stabilize the heart rate," she said. Some studies have shown kangaroo care can cut infant mortality by as much as a quarter. However, there's often not sufficient local education and support for this practice.
"It's a cheap, simple thing to do, but it has not been implemented everywhere," said Norheim, adding that he'd also like to see more education around early breastfeeding and better trained birth attendants who can intervene in high-risk deliveries.
Further reducing newborn fatalities, as well as child mortality more broadly, will require continued health investments, says Norheim. However, this is not guaranteed.
"In the early 2000s and up to 2015, we saw a very steady increase [in funding] and then it plateaued," he said. But since the pandemic, "we see actually in some countries a decline in the investment in the health budgets. So, many people working or doing research on health financing are concerned."
Norheim said he hopes the "amazing achievement" captured in the U.N. report is motivation to keep investing in further reducing child mortality. "There exist technologies, health services, living standards that would make it possible to get these numbers almost down to zero," he said.
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