Global, regional, national, and selected subnational levels of stillbirths, neonatal, infant, and under-5 mortality, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015
Authors: Haidong Wang, Zulfiqar A Bhutta, Matthew M Coates, Megan Coggeshall, Lalit Dandona, Khassoum Diallo, Elisabeth Barboza Franca, Maya Fraser, Nancy Fullman, Peter W Gething, Simon I Hay, Yohannes Kinfu, Maaya Kita, Xie Rachel Kulikoff, Heidi J Larson, Juan Liang, Xiaofeng Liang, Stephen S Lim, Margaret Lind, Alan D Lopez, Rafael Lozano, George A Mensah, Joseph B Mikesell, Ali H Mokdad, Meghan D Mooney, Mohsen Naghavi, Grant Nguyen, Ivo Rakovac, Joshua A Salomon, Naris Silpakit, Amber Sligar, Reed J D Sorensen, Theo Vos, Jun Zhu, Amanuel Alemu Abajobir, Kalkidan Hassen Abate, Kaja M Abbas, Foad Abd-Allah, Abdishakur M Abdulle, Semaw Ferede Abera, Victor Aboyans, Biju Abraham, Ibrahim Abubakar, Laith J Abu-Raddad, Niveen M E Abu-Rmeileh, Gebre Yitayih Abyu, Tom Achoki, Akindele Olupelumi Adebiyi, Isaac Akinkunmi Adedeji, Ademola Lukman Adelekan, Arsène Kouablan Adou, Arnav Agarwal, Oluremi N Ajala, Tomi F Akinyemiju, Nadia Akseer, Khurshid Alam, Noore K M Alam, Deena Alasfoor, Robert William Aldridge, Miguel Angel Alegretti, Zewdie Aderaw Alemu, Raghib Ali, Ala'a Alkerwi, François Alla, Rajaa Al-Raddadi, Ubai Alsharif, Khalid A Altirkawi, Elena Alvarez Martin, Nelson Alvis-Guzman, Azmeraw T Amare, Alemayehu Amberbir, Adeladza Kofi Amegah, Emmanuel A Ameh, Walid Ammar, Stephen Marc Amrock, Hjalte H Andersen, Gregory M Anderson, Carl Abelardo T Antonio, Johan Ärnlöv, Al Artaman, Hamid Asayesh, Rana Jawad Asghar, Reza Assadi, Suleman Atique, Euripide Frinel G Arthur Avokpaho, Ashish Awasthi, Beatriz Paulina Ayala Quintanilla, Umar Bacha, Alaa Badawi, Kalpana Balakrishnan, Amitava Banerjee, Bolanle F Banigbe, Aleksandra Barac, Ryan M Barber, Suzanne L Barker-Collo, Till Bärnighausen, Lope H Barrero, Tigist Assefa Bayou, Yibeltal Tebekaw Bayou, Shahrzad Bazargan-Hejazi, Justin Beardsley, Neeraj Bedi, Tolesa Bekele, Michelle L Bell, Aminu K Bello, Derrick A Bennett, Isabela M Bensenor, Adugnaw Berhane, Eduardo Bernabé, Balem Demtsu Betsu, Addisu Shunu Beyene, Samir Bhatt, Sibhatu Biadgilign, Boris Bikbov, Sait Mentes Birlik, Donal Bisanzio, Espen Bjertness, Jed D Blore, Rupert R A Bourne, Michael Brainin, Alexandra Brazinova, Nicholas J K Breitborde, Alexandria Brown, Geoffrey Colin Buckle, Michael Burch, Zahid A Butt, Ismael Ricardo Campos-Nonato, Julio Cesar Campuzano, Rosario Cárdenas, David O Carpenter, Juan Jesus Carrero, Austin Carter, Daniel C Casey, Carlos A Castañeda-Orjuela, Jacqueline Castillo Rivas, Ruben Estanislao Castro, Ferrán Catalá-López, Kelly Cercy, Hsing-Yi Chang, Jung-Chen Chang, Chioma Ezinne Chibueze, Vesper Hichilombwe Chisumpa, Jee-Young Jasmine Choi, Rajiv Chowdhury, Devasahayam Jesudas Christopher, Liliana G Ciobanu, Samantha M Colquhoun, Cyrus Cooper, Leslie Cornaby, Solomon Abrha Damtew, Hadi Danawi, Rakhi Dandona, José das Neves, Adrian C Davis, Pieter de Jager, Diego De Leo, Louisa Degenhardt, Kebede Deribe, Amare Deribew, Don C Des Jarlais, Gabrielle A deVeber, Samath D Dharmaratne, Preet K Dhillon, Eric L Ding, Pratik Pinal Doshi, Kerrie E Doyle, Leilei Duan, Manisha Dubey, Hedyeh Ebrahimi, Christian Lycke Ellingsen, Iqbal Elyazar, Aman Yesuf Endries, Sergey Petrovich Ermakov, Babak Eshrati, Alireza Esteghamati, Emerito Jose Aquino Faraon, Talha A Farid, Carla Sofia e Sa Farinha, André Faro, Maryam S Farvid, Farshad Farzadfar, Seyed-Mohammad Fereshtehnejad, Joao C Fernandes, Florian Fischer, Joseph R A Fitchett, Nataliya Foigt, Richard C Franklin, Joseph Friedman, Thomas Fürst, Ketevan Gambashidze, Amiran Gamkrelidze, Parthasarathi Ganguly, Teshome Gebre, Tsegaye Tewelde Gebrehiwot, Amanuel Tesfay Gebremedhin, Alemseged Aregay Gebru, Johanna M Geleijnse, Bradford D Gessner, Ibrahim Abdelmageem Mohamed Ginawi, Ababi Zergaw Giref, Melkamu Dedefo Gishu, Hector Gomez-Dantes, Philimon Gona, Amador Goodridge, Sameer Vali Gopalani, Atsushi Goto, Hebe N Gouda, Harish Chander Gugnani, Yuming Guo, Rahul Gupta, Rajeev Gupta, Vipin Gupta, Bishal Gyawali, Juanita A Haagsma, Nima Hafezi-Nejad, Demewoz Haile, Alemayehu Desalegne Hailu, Gessessew Bugssa Hailu, Randah Ribhi Hamadeh, Samer Hamidi, Jamie Hancock, Alexis J Handal, Graeme J Hankey, Hilda L Harb, Sivadasanpillai Harikrishnan, Kimani M Harun, Rasmus Havmoeller, Roderick J Hay, Ileana Beatriz Heredia-Pi, Hans W Hoek, Masako Horino, Nobuyuki Horita, H Dean Hosgood, Peter J Hotez, Damian G Hoy, Mohamed Hsairi, Guoqing Hu, Cheng Huang, John J Huang, Hsiang Huang, Laetitia Huiart, Chantal Huynh, Kim Moesgaard Iburg, Bulat T Idrisov, Kaire Innos, Kathryn H Jacobsen, Nader Jahanmehr, Mehdi Javanbakht, Achala Upendra Jayatilleke, Sun Ha Jee, Panniyammakal Jeemon, Vivekanand Jha, Guohong Jiang, Ying Jiang, Tariku Jibat, Ye Jin, Jost B Jonas, Zubair Kabir, Yogeshwar Kalkonde, Ritul Kamal, Haidong Kan, Gagandeep Kang, André Karch, Corine Kakizi Karema, Amir Kasaeian, Anil Kaul, Norito Kawakami, Jeanne Françoise Kayibanda, Konstantin Kazanjan, Peter Njenga Keiyoro, Andrew Haddon Kemp, Andre Pascal Kengne, Andre Keren, Maia Kereselidze, Chandrasekharan Nair Kesavachandran, Yousef Saleh Khader, Ibrahim A Khalil, Abdur Rahman Khan, Ejaz Ahmad Khan, Young-Ho Khang, Irma Khonelidze, Jagdish Khubchandani, Cho-il Kim, Daniel Kim, Yun Jin Kim, Niranjan Kissoon, Miia Kivipelto, Luke D Knibbs, Yoshihiro Kokubo, Soewarta Kosen, Parvaiz A Koul, Ai Koyanagi, Barthelemy Kuate Defo, Burcu Kucuk Bicer, Andreas A Kudom, G Anil Kumar, Michael J Kutz, Hmwe H Kyu, Dharmesh Kumar Lal, Ratilal Lalloo, Hilton Lam, Jennifer O Lam, Van C Lansingh, Anders Larsson, James Leigh, Ricky Leung, Yichong Li, Yongmei Li, M Patrice Lindsay, Patrick Y Liu, Shiwei Liu, Belinda K Lloyd, Warren D Lo, Giancarlo Logroscino, Nicola Low, Raimundas Lunevicius, Ronan A Lyons, Stefan Ma, Hassan Magdy Abd El Razek, Mohammed Magdy Abd El Razek, Mahdi Mahdavi, Marek Majdan, Azeem Majeed, Reza Malekzadeh, Chabila C Mapoma, Wagner Marcenes, Jose Martinez-Raga, Melvin Barrientos Marzan, Felix Masiye, John J McGrath, Peter A Meaney, Alem Mehari, Man Mohan Mehndiratta, Alemayehu B Mekonnen, Yohannes Adama Melaku, Peter Memiah, Ziad A Memish, Walter Mendoza, Atte Meretoja, Tuomo J Meretoja, Francis Apolinary Mhimbira, Ted R Miller, Edward J Mills, Mojde Mirarefin, Awoke Misganaw, Charles N Mock, Karzan Abdulmuhsin Mohammad, Alireza Mohammadi, Shafiu Mohammed, Lorenzo Monasta, Julio Cesar Montañez Hernandez, Marcella Montico, Ami R Moore, Maziar Moradi-Lakeh, Lidia Morawska, Rintaro Mori, Ulrich O Mueller, Georgina A V Murphy, Srinivas Murthy, Jean B Nachega, Aliya Naheed, Kovin S Naidoo, Luigi Naldi, Devina Nand, Vinay Nangia, Subas Neupane, Charles R Newton, John N Newton, Marie Ng, Frida Namnyak Ngalesoni, Peter Nguhiu, Quyen Le Nguyen, Muhammad Imran Nisar, Patrick Martial Nkamedjie Pete, Ole F Norheim, Rosana E Norman, Felix Akpojene Ogbo, In-Hwan Oh, Foluke Adetola Ojelabi, Pedro R Olivares, Bolajoko Olubukunola Olusanya, Jacob Olusegun Olusanya, Eyal Oren, Erika Ota, Mahesh PA, Eun-Kee Park, Hye-Youn Park, Mahboubeh Parsaeian, Angel J Paternina Caicedo, Scott B Patten, João Mário Pedro, David M Pereira, Norberto Perico, Konrad Pesudovs, Max Petzold, Michael Robert Phillips, Julian David Pillay, Farhad Pishgar, Suzanne Polinder, Daniel Pope, Svetlana Popova, Farshad Pourmalek, Mostafa Qorbani, Rynaz H S Rabiee, Anwar Rafay, Vafa Rahimi-Movaghar, Mahfuzar Rahman, Mohammad Hifz Ur Rahman, Sajjad Ur Rahman, Rajesh Kumar Rai, Murugesan Raju, Usha Ram, Saleem M Rana, Chhabi Lal Ranabhat, Puja Rao, Amany H Refaat, Giuseppe Remuzzi, Serge Resnikoff, Alex Reynolds, David Rojas-Rueda, Luca Ronfani, Gholamreza Roshandel, Gregory A Roth, Ambuj Roy, George Mugambage Ruhago, Rajesh Sagar, Muhammad Muhammad Saleh, Juan R Sanabria, Maria Dolores Sanchez-Niño, Itamar S Santos, João Vasco Santos, Rodrigo Sarmiento-Suarez, Benn Sartorius, Maheswar Satpathy, Miloje Savic, Monika Sawhney, Ione J C Schneider, Ben Schöttker, David C Schwebel, Soraya Seedat, Sadaf G Sepanlou, Edson E Servan-Mori, Tesfaye Setegn, Saeid Shahraz, Masood Ali Shaikh, Marina Shakh-Nazarova, Rajesh Sharma, Jun She, Sara Sheikhbahaei, Jiabin Shen, Kevin N Sheth, Kenji Shibuya, Hwashin Hyun Shin, Min-Jeong Shin, Rahman Shiri, Ivy Shuie, Inga Dora Sigfusdottir, Diego Augusto Santos Silva, Jonathan Silverberg, Edgar P Simard, Shireen Sindi, Abhishek Singh, Jasvinder A Singh, Om Prakash Singh, Prashant Kumar Singh, Virendra Singh, Joan B Soriano, Sergey Soshnikov, Luciano A Sposato, Chandrashekhar T Sreeramareddy, Vasiliki Stathopoulou, Nicholas Steel, Konstantinos Stroumpoulis, Lela Sturua, Bruno F Sunguya, Soumya Swaminathan, Bryan L Sykes, Cassandra E I Szoeke, Rafael Tabarés-Seisdedos, Mohammad Tavakkoli, Bineyam Taye, Bemnet Amare Tedla, Worku Mekonnen Tefera, Tesfaye Tekle, Girma Temam Shifa, Abdullah Sulieman Terkawi, Fisaha Haile Tesfay, Gizachew Assefa Tessema, Kiran Thapa, Alan J Thomson, Andrew L Thorne-Lyman, Ruoyan Tobe-Gai, Marcello Tonelli, Roman Topor-Madry, Fotis Topouzis, Bach Xuan Tran, Christopher Troeger, Thomas Truelsen, Zacharie Tsala Dimbuene, Abera Kenay Tura, Stefanos Tyrovolas, Kingsley N Ukwaja, Chigozie Jesse Uneke, Olalekan A Uthman, Masoud Vaezghasemi, Tommi Vasankari, Ana Maria Nogales Vasconcelos, Narayanaswamy Venketasubramanian, Raj Kumar Verma, Francesco S Violante, Sergey K Vladimirov, Vasiliy Victorovich Vlassov, Stein Emil Vollset, Linhong Wang, Yanping Wang, Scott Weichenthal, Elisabete Weiderpass, Robert G Weintraub, Daniel J Weiss, Andrea Werdecker, Ronny Westerman, Marc-Alain Widdowson, Tissa Wijeratne, Thomas Neil Williams, Charles Shey Wiysonge, Charles D A Wolfe, Ingrid Wolfe, Sungho Won, Mamo Wubshet, Qingyang Xiao, Gelin Xu, Ajit Kumar Yadav, Bereket Yakob, Yuichiro Yano, Mehdi Yaseri, Pengpeng Ye, Henock Gebremedhin Yebyo, Paul Yip, Naohiro Yonemoto, Seok-Jun Yoon, Mustafa Z Younis, Chuanhua Yu, Zoubida Zaidi, Maysaa El Sayed Zaki, Hajo Zeeb, Hao Zhang, Yong Zhao, Yingfeng Zheng, Maigeng Zhou, Sanjay Zodpey, Christopher J L Murray
Journal: The Lancet (2016)

BackgroundEstablished in 2000, Millennium Development Goal 4 (MDG4) catalysed extraordinary political, financial, and social commitments to reduce under-5 mortality by two-thirds between 1990 and 2015. At the country level, the pace of progress in improving child survival has varied markedly, highlighting a crucial need to further examine potential drivers of accelerated or slowed decreases in child mortality. The Global Burden of Disease 2015 Study (GBD 2015) provides an analytical framework to comprehensively assess these trends for under-5 mortality, age-specific and cause-specific mortality among children under 5 years, and stillbirths by geography over time.MethodsDrawing from analytical approaches developed and refined in previous iterations of the GBD study, we generated updated estimates of child mortality by age group (neonatal, post-neonatal, ages 1–4 years, and under 5) for 195 countries and territories and selected subnational geographies, from 1980–2015. We also estimated numbers and rates of stillbirths for these geographies and years. Gaussian process regression with data source adjustments for sampling and non-sampling bias was applied to synthesise input data for under-5 mortality for each geography. Age-specific mortality estimates were generated through a two-stage age–sex splitting process, and stillbirth estimates were produced with a mixed-effects model, which accounted for variable stillbirth definitions and data source-specific biases. For GBD 2015, we did a series of novel analyses to systematically quantify the drivers of trends in child mortality across geographies. First, we assessed observed and expected levels and annualised rates of decrease for under-5 mortality and stillbirths as they related to the Soci-demographic Index (SDI). Second, we examined the ratio of recorded and expected levels of child mortality, on the basis of SDI, across geographies, as well as differences in recorded and expected annualised rates of change for under-5 mortality. Third, we analysed levels and cause compositions of under-5 mortality, across time and geographies, as they related to rising SDI. Finally, we decomposed the changes in under-5 mortality to changes in SDI at the global level, as well as changes in leading causes of under-5 deaths for countries and territories. We documented each step of the GBD 2015 child mortality estimation process, as well as data sources, in accordance with the Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER).FindingsGlobally, 5·8 million (95% uncertainty interval [UI] 5·7–6·0) children younger than 5 years died in 2015, representing a 52·0% (95% UI 50·7–53·3) decrease in the number of under-5 deaths since 1990. Neonatal deaths and stillbirths fell at a slower pace since 1990, decreasing by 42·4% (41·3–43·6) to 2·6 million (2·6–2·7) neonatal deaths and 47·0% (35·1–57·0) to 2·1 million (1·8-2·5) stillbirths in 2015. Between 1990 and 2015, global under-5 mortality decreased at an annualised rate of decrease of 3·0% (2·6–3·3), falling short of the 4·4% annualised rate of decrease required to achieve MDG4. During this time, 58 countries met or exceeded the pace of progress required to meet MDG4. Between 2000, the year MDG4 was formally enacted, and 2015, 28 additional countries that did not achieve the 4·4% rate of decrease from 1990 met the MDG4 pace of decrease. However, absolute levels of under-5 mortality remained high in many countries, with 11 countries still recording rates exceeding 100 per 1000 livebirths in 2015. Marked decreases in under-5 deaths due to a number of communicable diseases, including lower respiratory infections, diarrhoeal diseases, measles, and malaria, accounted for much of the progress in lowering overall under-5 mortality in low-income countries. Compared with gains achieved for infectious diseases and nutritional deficiencies, the persisting toll of neonatal conditions and congenital anomalies on child survival became evident, especially in low-income and low-middle-income countries. We found sizeable heterogeneities in comparing observed and expected rates of under-5 mortality, as well as differences in observed and expected rates of change for under-5 mortality. At the global level, we recorded a divergence in observed and expected levels of under-5 mortality starting in 2000, with the observed trend falling much faster than what was expected based on SDI through 2015. Between 2000 and 2015, the world recorded 10·3 million fewer under-5 deaths than expected on the basis of improving SDI alone.InterpretationGains in child survival have been large, widespread, and in many places in the world, faster than what was anticipated based on improving levels of development. Yet some countries, particularly in sub-Saharan Africa, still had high rates of under-5 mortality in 2015. Unless these countries are able to accelerate reductions in child deaths at an extraordinary pace, their achievement of proposed SDG targets is unlikely. Improving the evidence base on drivers that might hasten the pace of progress for child survival, ranging from cost-effective intervention packages to innovative financing mechanisms, is vital to charting the pathways for ultimately ending preventable child deaths by 2030.FundingBill & Melinda Gates Foundation.