Levels & Trends in 2019 Report 2014 Child developed by Estimates Developed Estimates the by the Mortality Inter-agencyGroup UN Inter-agency UN Group for for MortalityEstimation Child Mortality Child Estimation United Nations This report was prepared at UNICEF headquarters by Lucia Hug, David Sharrow and Danzhen You, with support from Mark Hereward and Yanhong Zhang, on behalf of the United Nations Inter-agency Group for Child Mortality Estimation (UN IGME). Organizations and individuals involved in generating country-specific estimates of child mortality United Nations Children’s Fund Lucia Hug, Sinae Lee, David Sharrow, Danzhen You World Health Organization Bochen Cao, Jessica Ho, Wahyu Retno Mahanani, Kathleen Louise Strong World Bank Group Emi Suzuki United Nations, Department of Economic and Social Affairs, Population Division Kirill Andreev, Lina Bassarsky, Victor Gaigbe-Togbe, Patrick Gerland, Danan Gu, Sara Hertog, Nan Li, Thomas Spoorenberg, Philipp Ueffing, Mark Wheldon United Nations Economic Commission for Latin America and the Caribbean, Population Division Guiomar Bay, Helena Cruz Castanheira Special thanks to the Technical Advisory Group of the UN IGME for providing technical guidance on methods for child mortality estimation Leontine Alkema, University of Massachusetts, Amherst Kenneth Hill (Chair), Stanton-Hill Research Robert Black, Johns Hopkins University Bruno Masquelier, University of Louvain Simon Cousens, London School of Hygiene & Tropical Medicine Colin Mathers, University of Edinburgh Trevor Croft, The Demographic and Health Surveys (DHS) Program, ICF Jon Pedersen, Fafo Michel Guillot, University of Pennsylvania and French Institute for Jon Wakefield, University of Washington Demographic Studies (INED) Neff Walker, Johns Hopkins University Special thanks to the United States Agency for International Development (USAID) and the Bill & Melinda Gates Foundation for supporting UNICEF’s child mortality estimation work. Thanks also go to the Joint United Nations Programme on HIV/AIDS for sharing estimates of AIDS mortality, Rob Dorrington from the University of Cape Town for providing data for South Africa, Jing Liu from Fafo for preparing the underlying data, and Zitong Wang for supporting further data processing and analysis. Thanks also go to the Maternal and Child Epidemiology Estimation Group (MCEE) for providing interim estimates of cause of death for children under 5 years of age, work which involved Robert Black, Li Liu, Jamie Perin, Francisco Villavicencio and Diana Yeung from Johns Hopkins University; Simon Cousens, Amy Mulick, Shefali Oza and David Prieto-Merino from the London School of Hygiene & Tropical Medicine; and Regina Guthold, Dan Hogan, Colin Mathers and Gerard Lopez from WHO. And special thanks to UNICEF and WHO field office colleagues for supporting the country consultations and regional workshops. Thanks also go to Khin Wityee Oo from UNICEF for proofreading and to other UNICEF colleagues, including: Vidhya Ganesh (Director, Division of Data, Analytics, Planning and Monitoring), Mark Hereward (Associate Director, Data and Analytics Section, Division of Data, Analytics, Planning and Monitoring), Yanhong Zhang, Attila Hancioglu, Karen Avanesyan, Sebastian Bania, Karen Carter, Liliana Carvajal, Yadigar Coskun, Enrique Delamónica, Ahmed Hanafy, Karoline Hassfurter, Yves Jaques, Shane Khan, Richard Kumapley, Rada Noeva, Daniele Olivetti, Eva Quintana, Anshana Ranck, Jennifer Requejo, Turgay Unalan and Upasana Young. Thanks to Theresa Diaz from WHO, Mary Mahy and Juliana Daher from the Joint United Nations Programme on HIV/AIDS, William Weiss and Robert Cohen from USAID, and Kate Somers, Savitha Subramanian, Laura Lamberti and Assaye Nigussie from the Bill & Melinda Gates Foundation for their support. Special thanks also to the many government agencies in countries for providing data and valuable feedback through the country consultation process. Naomi Lindt edited the report. Sinae Lee laid out the report. Copyright © 2019 by the United Nations Children’s Fund The United Nations Inter-agency Group for Child Mortality Estimation (UN IGME) constitutes representatives of the United Nations Children’s Fund (UNICEF), the World Health Organization (WHO), the World Bank Group and the United Nations Population Division. Differences between the estimates presented in this report and those in forthcoming publications by UN IGME members may arise because of differences in reporting periods or in the availability of data and other evidence during the production process of each publication. UN IGME estimates were reviewed by countries through a country consultation process but are not necessarily the official statistics of United Nations Member States, which may use a single data source or alternative rigorous methods. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of UNICEF, WHO, the World Bank Group or the United Nations Population Division concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. United Nations Children’s Fund World Bank Group 3 UN Plaza, New York, New York, 10017 USA 1818 H Street, NW, Washington, DC, 20433 USA World Health Organization United Nations Population Division Avenue Appia 20, 1211 Geneva 27, Switzerland 2 UN Plaza, New York, New York, 10017 USA Levels & Trends in Child Mortality Report 2019 Estimates developed by the UN Inter-agency Group for Child Mortality Estimation CHILD SURVIVAL: KEY FACTS AND FIGURES • Tremendous progress in child survival has been (30, 31) in 2000 – a 52 (47, 53) per cent and 42 made over the past two decades. The total (37, 45) per cent decline, respectively. number of deaths among children and young adolescents under 15 years of age dropped • The total number of under-five deaths dropped by 56 per cent from 14.2 (14.0, 14.5)1 million to 5.3 (5.1, 5.7) million in 2018 from 12.5 (12.4, in 1990 to 6.2 (6.0, 6.7) million in 2018. Still, 12.7) million in 1990. On average, 15,000 one child or young adolescent died every five children died before age 5 every day in 2018 seconds in 2018. compared to 34,000 in 1990 and 27,000 in 2000. Among the 5.3 million under-five deaths in 2018, • Globally, 85 per cent of deaths among children 2.9 (2.8, 3.1) million were boys and 2.4 (2.3, 2.6) and young adolescents in 2018 occurred in million were girls. the first five years of life, accounting for 5.3 million deaths, of which 2.5 million (47 per cent) • The global number of neonatal deaths declined occurred in the first month of life, 1.5 million (29 from 5.0 (4.9, 5.2) million in 1990 to 2.5 (2.4, 2.7) per cent) at age 1–11 months, and 1.3 million million 2018 – 7,000 deaths every day in 2018 (25 per cent) at age 1−4 years. An additional 0.9 compared with 14,000 in 1990. Neonatal deaths million deaths occurred among children aged accounted for 47 (45, 49) per cent of all under- 5−14 years. five deaths in 2018, increasing from 40 (39, 41) per cent in 1990 due to a faster global decline • Among children and young adolescents under in mortality among children aged 1–59 months 15 years of age, the risk of dying was highest than for children in their first month of life. in the first month of life, at an average rate of 18 (17, 19) deaths per 1,000 live births globally • For older children and young adolescents aged in 2018. In comparison, the probability of dying 5−14 years, the probability of dying continues after the first month and before reaching age to decline, dropping from 15 (15, 16) deaths per 1 was 11 (11, 12) per 1,000, the probability of 1,000 children aged 5 in 1990 to 7 (7, 8) in 2018. dying after reaching age 1 and before reaching The total number of deaths in this age group age 5 was 10 (9, 11) per 1,000, and the dropped from 1.7 (1.7, 1.8) million in 1990 to 1.4 probability of dying after reaching age 5 and (1.4, 1.5) million in 2000 and to 0.9 (0.9, 1.0) before reaching age 15 was 7 (7, 8) per 1,000. million in 2018. • The global under-five mortality rate fell to 39 • Children continue to face widespread regional (37, 42) deaths per 1,000 live births in 2018 disparities in their chances of survival. Sub- from 93 (92, 95) in 1990 and 76 (75, 78) in 2000 Saharan Africa remains the region with the – a 59 (55, 60) per cent and 49 (46, 52) per cent highest under-five mortality rate in the world. decline, respectively. The neonatal mortality In 2018, the region had an average under-five rate fell to 18 (17, 19) deaths per 1,000 live mortality rate of 78 deaths per 1,000 live births. births in 2018 from 37 (36, 38) in 1990 and 31 This translates to 1 in 13 children dying before 4 his or her fifth birthday – 16 times higher than the • In 2018, 121 countries had already achieved an average ratio of 1 in 199 in high-income countries. under-five mortality rate below the Sustainable Development Goal (SDG) target of 25 or fewer • It is urgent to further accelerate progress in preventing deaths per 1,000 live births; those countries child deaths. Current trends predict that close to 10 should aim to maintain progress and further million 5- to 14-year-olds and 52 million children under reduce disparities among their populations. Of the 5 years of age will die between 2019 and 2030. Almost remaining 74 countries, progress will need to be half of these under-five deaths will be newborns whose accelerated in 53 to reach the SDG target by 2030. deaths can be prevented by reaching high coverage of quality antenatal care, skilled care at birth, postnatal • If all countries reach the SDG child survival targets care for mother and baby, and care of small and sick by 2030, 11 million lives under age 5 will be saved newborns. – more than half of them in sub-Saharan Africa. Global mortality rates and deaths by age Children under age 5 Neonatal Children and adolescents aged 5–14 years Mortality rate (probability of dying per 1,000) Number of deaths (in millions) 39 5.3 2018 18 7 2.5 0.9 9.8 76 2000 31 12 4.0 1.4 12.5 93 1990 37 15 5.0 1.7 5 Introduction Thirty years ago, the world made a commitment Strategy for Women’s, Children’s and Adolescents’ to protect and fulfil children’s rights as enshrined Health (2016–2030)3 and the Sustainable in the Convention on the Rights of the Child. Development Goals (SDGs).4 The third SDG calls Among the most fundamental of these rights for an end to preventable deaths of newborns and is the right of every child to survive.2 While children under age 5, with all countries aiming substantial progress in child survival has been to reduce neonatal mortality to at least as low made since then, the failure to fully meet that as 12 deaths per 1,000 live births and under-five commitment reverberates today for millions of mortality to at least as low as 25 deaths per 1,000 children: In 2018 alone, 5.3 million children died live births by 2030. before reaching their fifth birthday and almost 1 million children aged 5–14 years died. Sound policies, concerted efforts and appropriate resources are needed to accelerate progress and It is especially unacceptable that these children achieve the child survival goals. If current trends and young adolescents died largely of preventable continue, 53 countries will not meet the SDG or treatable causes like infectious diseases and target on under-five mortality by 2030. This would injuries when we have the means to prevent these result in 11 million excess child deaths between deaths. The continued burden of child deaths is a 2019 and 2030 in addition to the 41 million call to redouble efforts to realize the Convention’s children who will die before age 5 between 2019 promise and other international human rights and 2030, even if all countries meet the SDG commitments that protect every child’s right to target by 2030. survive. Protecting every child’s right to survive will Although the global number of child deaths require addressing persistent inequities and remains high, the world has made tremendous disparities in maternal and child health while strides in reducing child and young adolescent also ensuring universal access to safe, effective, mortality over the past few decades. The global high-quality and affordable care for women, under-five mortality rate declined by 59 per cent children and adolescents. It also demands great from 93 deaths per 1,000 live births in 1990 to understanding of levels and trends in child 39 in 2018, while mortality among children aged mortality, as well as the underlying causes of 5–14 years fell by 53 per cent from 15 to 7 deaths child and young adolescent deaths to help guide per 1,000 children aged 5. Still, the burden of policymaking and planning. child deaths remains immense – the number of children aged 0–14 years that died in 2018, 6.2 Given the absence of reliable vital registration million, is equivalent to the current population of data in many countries – an important resource Nicaragua. for monitoring births and deaths – evidence- based estimation of child mortality remains The global community recognizes the urgent a cornerstone for tracking progress towards need to end preventable child deaths, making it child survival goals. These estimates enable an essential part of global child survival goals and governments, international organizations initiatives including the United Nations Global and other stakeholders to set priorities and 6 plan national and global health strategies and on child and adolescent mortality. This report interventions. presents the UN IGME’s latest estimates – through 2018 – of neonatal, infant and under-five mortality The United Nations Inter-agency Group for as well as mortality among children aged 5–14 Child Mortality Estimation (UN IGME) produces years.5 It assesses progress in the reduction of estimates of child and young adolescent mortality child and young adolescent mortality at the annually, reconciling the differences across data country, regional and global levels, and provides sources and taking into account the systematic an overview of the methods used to estimate the biases associated with the various types of data mortality indicators mentioned above. 7 Levels and Trends in Child Mortality Despite progress over the past two decades, in births globally. The probability of dying after 2018 alone, an estimated 6.2 million children the first month and before reaching age 1 was at and young adolescents under age 15 died, mostly 11 per 1,000, and the probability of dying after from preventable causes. Newborns account for reaching age 1 and before reaching age 5 was at 2.5 million of these deaths, children aged 1−11 10 per 1,000. For children aged 5–14 years, the months for 1.5 million, children aged 1−4 years for probability of dying was estimated at 7 per 1,000 1.3 million, children aged 5−9 years for 560,000 children aged 5 years, with the probability of and young adolescents aged 10−14 years for dying after reaching age 5 and before reaching 360,000 (Figure 1, Figure 2). age 10 at 4 deaths per 1,000 and 3 per 1,000 for young adolescents aged 10–14 years (Figure 1). The youngest children face the greatest risk of dying among children under age 15. The age The vast majority of child and young adolescent distribution of the mortality of children and deaths occur at the youngest ages. Of the 6.2 young adolescents shows that the highest risk of million deaths in 2018, 85 per cent (5.3 million) death is during the neonatal period (the first occurred in the first five years of life (Figure 1). 28 days of life). In 2018, the neonatal mortality About half (47 per cent) of the under-five deaths rate was estimated at 18 deaths per 1,000 live occurred in the neonatal period (2.5 million). FIGURE In the first month, the mortality risk is the highest 1 Global mortality rates and number of deaths by age, 2018 Mortality rates Number of deaths (in millions and percentage share) Children aged 10−14 years Children aged 40 39 5–14 years 0.36 (6%) Children aged 0.9 (15%) 5−9 years 0.56 (9%) Children aged 1–4 years 30 1.3 (21%) Deaths per 1,000 Children aged 1–11 months Under-five 20 18 1.5 (24%) 5.3 (85%) 11 10 10 Neonatal 7 2.5 (40%) 4 3 Neonatal Children Children Children Children Under-five Children aged 1–11 aged 1–4 aged 5−9 aged 10–14 aged 5–14 months years years years years Note: All figures are based on unrounded numbers. 8 The burden is uneven across regions. In 2018, 1990–2000 and 2.7 (2.1, 3.0) per cent for 2000– more than half (3.3 million) of all children 2018. Regionally, sub-Saharan Africa, Oceania under age 15 died in sub-Saharan Africa (excluding Australia and New Zealand), Central followed by Central and Southern Asia with 28 and Southern Asia, and Eastern and South- per cent (1.8 million). The regions of Australia Eastern Asia saw acceleration in under-five and New Zealand, Eastern and South-Eastern mortality decline since 2000. Notably, Eastern Asia, Northern Africa and Western Asia, Europe and South-Eastern Asia had the largest ARR for and Northern America, Latin America and the both under-five and neonatal mortality among Caribbean and Oceania (excluding Australia and all regions and periods. In the region, the ARR New Zealand) account for the remaining 19 per for under-five mortality increased from 3.6 (3.0, cent or 1.2 million deaths of children under 15 4.2) to 5.5 (5.0, 5.9) per cent and for neonatal years of age. mortality from 3.1 (2.2, 4.1) to 5.6 (4.9, 6.1) per cent over the two periods. For older children aged Declines in mortality among children under age 5–14 years, Central and Southern Asia had the 5 have accelerated since 2000, but the pace of largest ARR at 4.5 (3.6, 5.3) per cent for 2000– decline remained at similar levels for children 2018, up from 3.8 (3.3, 4.3) per cent during the aged 5–14 years. Globally, the annual rate of 1990s (Figure 3). reduction (ARR)6 in under-five mortality nearly doubled from 2.0 (1.8, 2.1) per cent in 1990– Child mortality under age 5 2000 to 3.8 (3.4, 4.0) per cent in 2000–2018, while the ARR for neonatal mortality increased Under-five mortality from 1.8 (1.5, 2.1) per cent in 1990–2000 to 3.0 Millions of children have better survival chances (2.6, 3.3) per cent in 2000–2018. For children today than in 1990. The under-five mortality aged 5–14 years, the ARR remained constant rate was reduced by 59 (55, 60) per cent from 93 over the two periods at 2.7 (2.4, 3.1) per cent for (92, 95) in 1990 to 39 (37, 42) deaths per 1,000 FIGURE Globally, child mortality declined by more than half for children under age 5 and children aged 5−14 2 years since 1990 Global mortality rates and number of deaths by age, 1990–2018 Mortality rates Number of deaths 100 93 12.5 75 11.3 9.8 Deaths (in millions) Deaths per 1,000 8.3 50 37 39 ●● 7.0 ● ● ● 5.0 4.5 4.0 5.8 ●5.3 25 15 18 ● 3.5 ● ● ● 3.1 2.7 2.5 7 ● ● ● ● ● ● ● 1.7 1.6 1.4 1.3 0 1.1 1.0 0.9 1990 1995 2000 2005 2010 2015 2018 1990 1995 2000 2005 2010 2015 2018 Under-five Neonatal Mortality rate among Under-five Neonatal Deaths among children mortality rate mortality rate children aged 5–14 years deaths deaths aged 5–14 years Note: All figures are based on unrounded numbers. The solid line in the left panel represents the median estimate and the shaded area represents the 90 per cent uncertainty bound around the median value. 9 FIGURE Globally, declines in mortality among children under age 5 have accelerated since 2000, but the pace 3 of decline remained at similar levels for children aged 5–14 years Annual rate of reduction (per cent) in mortality rate by age group and Sustainable Development Goal region in 1990–2000 and 2000–2018 1990–2000 2000-2018 Children Children Children aged 5–14 aged 5–14 aged 5–14 Neonatal Under-five years Neonatal Under-five years Neonatal Under-five years 0 1.1 2 1.6 Per cent 2.1 2.2 2.3 2.8 2.7 2.9 3.1 3.2 3.4 4 3.7 3.8 3.8 3.8 3.9 4.6 4.5 6 Sub-Saharan Africa Northern Africa and Western Asia Central and Southern Asia Children Children Children aged 5–14 aged 5–14 aged 5–14 Neonatal Under-five years Neonatal Under-five years Neonatal Under-five years 0 2 Per cent 2.0 2.3 2.6 2.6 3.1 2.9 3.1 3.3 3.4 4 3.6 3.6 3.8 3.8 4.1 4.0 5.1 6 5.6 5.5 Eastern and South-Eastern Asia Latin America and the Caribbean Australia and New Zealand Children Children Children aged 5–14 aged 5–14 aged 5–14 Neonatal Under-five years Neonatal Under-five years Neonatal Under-five years 0 0.8 2 1.4 1.5 1.7 1.8 2.0 Per cent 2.1 2.1 2.7 2.7 2.7 3.0 3.0 3.0 4 3.4 3.4 3.8 3.8 6 Oceania (exc. Australia and New Zealand) Europe and Northern America World Note: All calculations are based on unrounded numbers. live births in 2018 (Table 1 and Figure 4). This 9.8 (9.7, 10.0) in 2000 (Table 2). On average, is equivalent to 1 in 11 children dying before 15,000 children died every day in 2018, compared reaching age 5 in 1990, compared to 1 in 26 in to 34,000 in 1990 and 27,000 in 2000. In 2018, 2018. In most of the SDG regions,7 the under- only six countries had an under-five mortality rate five mortality rate was reduced by at least half above 100 deaths per 1,000 live births, compared since 1990. More than 80 countries, including 31 to more than 50 countries in 1990. low- and lower middle-income countries, reduced their under-five mortality by more than two thirds Still, children face widespread regional over the same period. The total number of under- disparities in their chances of survival. Sub- five deaths dropped to 5.3 (5.1, 5.7) million in Saharan Africa continues to be the region with 2018 from 12.5 (12.4, 12.7) million in 1990 and the highest under-five mortality rate in the 10 TABLE 1  Levels and trends in the under-five mortality rate by Sustainable Development Goal region, 1990–2018 Under-five mortality rate Decline Annual rate of reduction (deaths per 1,000 live births) (per cent) (per cent) Region 1990 1995 2000 2005 2010 2015 2018 1990–2018 1990–2018 1990–2000 2000–2018 Sub-Saharan Africa 182 174 155 127 102 85 78 57 3.0 1.6 3.8 Northern Africa and Western Asia 74 62 50 40 32 28 26 65 3.8 3.9 3.7 Northern Africa 84 71 59 48 39 33 30 64 3.6 3.5 3.7 Western Asia 65 53 42 32 26 23 21 67 4.0 4.4 3.8 Central and Southern Asia 124 108 91 75 60 46 40 68 4.0 3.1 4.6 Central Asia 72 73 63 47 35 26 23 68 4.1 1.4 5.6 Southern Asia 126 110 92 76 61 47 41 68 4.0 3.1 4.5 Eastern and South-Eastern Asia 57 49 40 29 22 17 15 74 4.8 3.6 5.5 Eastern Asia 51 45 35 23 15 10 8 83 6.4 3.8 7.9 South-Eastern Asia 72 58 48 40 33 28 25 65 3.7 4.0 3.6 Latin America and the Caribbean 55 43 33 25 24 18 16 70 4.3 5.1 3.8 Oceania 36 33 32 29 25 22 21 42 1.9 1.1 2.4 Australia and New Zealand 10 7 6 6 5 4 4 58 3.1 4.0 2.6 Oceania (exc. Australia and New Zealand) 74 68 63 57 52 46 43 42 2.0 1.7 2.1 Europe and Northern America 14 12 10 8 7 6 6 60 3.3 3.8 3.0 Europe 15 13 10 8 7 6 5 67 4.0 3.9 4.0 Northern America 11 9 8 8 7 7 6 42 1.9 2.8 1.4 Landlocked developing countries 167 157 137 109 83 65 58 66 3.8 2.0 4.8 Least developed countries 175 159 137 110 89 71 64 63 3.6 2.5 4.2 Small island developing States 78 69 61 54 79 43 40 50 2.4 2.6 2.4 World 93 87 76 63 51 42 39 59 3.1 2.0 3.8 Note: All calculations are based on unrounded numbers. FIGURE Across all regions, under-five mortality declined between 1990 and 2018 4 Under-five mortality rate (deaths per 1,000 live births) by Sustainable Development Goal region, 1990, 2000 and 2018 1990 2000 2018 SDG country target for 2030 200 182 175 167 155 150 137 137 124 100 91 93 78 74 78 74 76 63 64 61 55 57 58 50 50 43 40 40 40 39 33 26 25 16 15 14 10 10 6 6 4 0 Sub-Saharan Oceania Central and Northern Latin America Eastern and Europe and Australia and Landlocked Least Small island World Africa (exc. Australia Southern Africa and and the South-Eastern Northern New Zealand developing developed developing and New Zealand) Asia Western Caribbean Asia America countries countries States Asia Note: All figures are based on unrounded numbers. 11 MAP Children in Sub-Saharan Africa and Southern Asia face higher risks of dying before their fifth birthday 1 Under-five mortality rate (deaths per 1,000 live births) by country, 2018 Under-five mortality rate (deaths per 1,000 live births) >100 75 to 100 40 to 75 25 to 40 10 to 25 ≤10 No data Note: The classification is based on unrounded numbers. This map does not reflect a position by UN IGME agencies on the legal status of any country or territory or the delimitation of any frontiers. world – 78 deaths per 1,000 live births in 2018 Pakistan, the Democratic Republic of the Congo (Table 1 and Figure 4). This translates to 1 child and Ethiopia. India and Nigeria alone account for in 13 dying before his or her fifth birthday – 16 about a third. times higher than the average ratio of 1 in 199 in high-income countries and roughly 20 years Fewer countries showed gender disparities in behind the world average, which achieved a 1 in child mortality. On average, boys are expected to 13 ratio by 1999. At the country level, the under- have a higher probability of dying before reaching five mortality rates in 2018 ranged from 2 deaths age 5 than girls. The estimated under-five per 1,000 live births to 122 (Map 1) – the risk of mortality rate in 2018 was 41 (39, 44) deaths per dying before the fifth birthday for a child born 1,000 live births for boys and 36 (35, 39) for girls. in the highest-mortality country was about 72 In 2018, an estimated 2.9 (2.8, 3.1) million boys times higher than in the lowest-mortality country. and 2.4 (2.3, 2.6) million girls under 5 years of All six countries with mortality rates above 100 age died (Figure 5). In some countries, the risk of deaths per 1,000 live births are in sub-Saharan dying before age 5 for girls is significantly higher Africa. than what would be expected based on global patterns. These countries are primarily located in Two regions bear most of the global burden of Southern Asia and Western Asia. The number of under-five deaths. In sub-Saharan Africa alone, countries showing higher than expected mortality 2.8 (2.6, 3.1) million children under age 5 died for girls fell by two thirds from 21 to 7 since 1990. – 52 per cent of all under-five deaths – and 1.5 (1.4, 1.7) million (29 per cent) died in Central Progress was remarkable but differed across and Southern Asia (Table 2). Together, the two countries and regions, and relative disparities regions account for more than 80 per cent of the remain. All eight SDG regions made progress in 5.3 million under-five deaths in 2018, – while they reducing under-five mortality, with the average only account for 52 per cent of the global under- annual rate of reduction ranging between 2.0 five population.8 Half of all under-five deaths in and 4.8 per cent from 1990 to 2018. The absolute 2018 occurred in five countries: India, Nigeria, decreases in the regions ranged from 6 deaths 12 TABLE Levels and trends in the number of deaths of children under age 5 by Sustainable Development Goal 2  region, 1990–2018 Share of global Number of under-five deaths Decline under-five deaths (thousands) (per cent) (per cent) Region 1990 1995 2000 2005 2010 2015 2018 1990–2018 1990 2000 2018 Sub-Saharan Africa 3,751 3,975 3,936 3,596 3,213 2,922 2,789 26 29.9 40.0 52.4 Northern Africa and Western Asia 681 567 460 383 341 318 296 57 5.4 4.7 5.6 Northern Africa 381 314 256 221 205 193 179 53 3.0 2.6 3.4 Western Asia 300 253 204 162 136 125 117 61 2.4 2.1 2.2 Central and Southern Asia 4,958 4,358 3,687 3,024 2,357 1,783 1,534 69 39.6 37.5 28.8 Central Asia 112 104 76 59 52 43 38 66 0.9 0.8 0.7 Southern Asia 4,846 4,254 3,611 2,965 2,305 1,740 1,497 69 38.7 36.7 28.1 Eastern and South-Eastern Asia 2,284 1,688 1,242 893 680 527 448 80 18.2 12.6 8.4 Eastern Asia 1,422 1,007 691 430 292 201 157 89 11.4 7.0 3.0 South-Eastern Asia 862 681 551 462 389 326 291 66 6.9 5.6 5.5 Latin America and the Caribbean 641 501 377 282 262 190 172 73 5.1 3.8 3.2 Oceania 19 18 18 17 16 15 14 25 0.1 0.2 0.3 Australia and New Zealand 3 2 2 2 2 2 2 49 0.0 0.0 0.0 Oceania (exc. Australia and New Zealand) 16 16 16 15 14 13 13 20 0.1 0.2 0.2 Europe and Northern America 191 143 112 96 85 74 67 65 1.5 1.1 1.3 Europe 144 103 76 62 53 46 40 72 1.1 0.8 0.7 Northern America 47 40 35 35 32 29 27 42 0.4 0.4 0.5 Landlocked developing countries 1,757 1,765 1,645 1,406 1,178 980 897 49 14.0 16.7 16.9 Least developed countries 3,605 3,558 3,330 2,895 2,508 2,136 1,992 45 28.8 33.9 37.4 Small island developing States 93 83 73 65 96 52 48 48 0.7 0.7 0.9 World 12,524 11,250 9,831 8,292 6,955 5,828 5,322 58 100.0 100.0 100.0 Note: All calculations are based on unrounded numbers. FIGURE On average, boys have a higher probability of dying before reaching age 5 than girls 5 Under-five mortality rate and number of under-five deaths by sex and Sustainable Development Goal region, 2018 Under-five mortality rate Number of Female Male under-five deaths (deaths per 1,000 live births) 0 25 50 75 100 (in thousands) Sub-Saharan Africa ● ● 1,268 1,521 Oceania (exc. Australia and New Zealand) ● ● 6 7 Central and Southern Asia ● ● 721 813 Northern Africa and Western Asia ●● 133 163 Latin America and the Caribbean ●● 75 97 Eastern and South-Eastern Asia ●● 194 254 Europe and Northern America ● ● 30 38 Australia and New Zealand ● ● 1 1 Landlocked developing countries ● ● 404 494 Least developed countries ● ● 904 1,088 Small island developing States ● ● 21 27 World ●● 2,427 2,894 Note: This figure shows unrounded under-five mortality rates. 13 to 104 deaths per 1,000 live births over the same period. Higher mortality regions recorded the FIGURE Countries with high to very high mortality levels highest absolute declines and the differences 6 tended to make faster progress in reducing mortality since 2000 than during the 1990s between the regions narrowed. However, relative Annual rate of reduction in the under-five mortality rate, disparities remained at similar levels for children 1990–2000 and 2000–2018 under 5 in sub-Saharan Africa compared to children in low mortality regions. Children under 5 in sub-Saharan Africa face a risk of death that is 20 times higher than in the region of Australia 10 and New Zealand and 14 times higher than in Europe and Northern America. 8 Annual rate of reduction 2000−2018 (per cent) 6 Countries with high to very high mortality levels tended to make faster progress in mortality 4 decline since 2000 than during the 1990s. In almost half of all countries (95 of 195 countries), 2 mortality declined more quickly in the 2000–2018 period compared to the 1990s, while for countries 0 with high or very high under-five mortality rates 00 (exceeding 50 deaths per 1,000 live births) in 20 −2 e 00 nc 20 Level of under-five mortality si 2018, that number was 84 per cent (32 of 38 re ss or e (deaths per 1,000 live births) in 2018 g ef Very high (>70) countries). Overall, 36 countries saw mortality ro sb −4 rp es High (50−70) ste ogr decline at least three times faster in 2000–2018 Fa er pr Moderate (25−50) Low (10−25) st than in 1990–2000 – 13 of those countries had −6 Fa Very low (≤10) high or very high mortality rates in 2018, and four −6 −4 −2 0 2 4 6 8 10 of those countries reversed a negative trend over Annual rate of reduction 1990−2000 (per cent) the two periods (Figure 6). Note: All calculations are based on unrounded numbers. Fragile contexts pose an elevated risk of death for children and a challenge to achieving the middle-income countries showed reductions SGD targets. On average, the under-five mortality for absolute disparities between children in rate in the 58 countries classified as ‘fragile’ the poorest and richest households within based on the OECD definition9 was three times countries since 1990 but with persisting relative higher than in all other countries in 2018. The disparities.10 Another study in Africa revealed under-five mortality rate for fragile countries that while the under-five mortality rate has was estimated at 66 (62, 73) deaths per 1,000 live been falling across areas within countries, births in 2018, almost 70 per cent higher than the the rate of reduction and most recent levels global average of 39 deaths per 1,000 live births, varied considerably.11 It also pointed out that and more than two thirds of the global under- differences within countries in Africa were five deaths in 2018 occurred in fragile countries. larger in areas with higher levels of under-five Of the countries with fragile context, children mortality and modest reductions. in ‘extremely fragile’ context had an even higher under-five mortality rate of 70 (62, 82) deaths per More than 50 countries need to accelerate 1,000 live births. The high mortality and relatively reductions in under-five mortality to reach slow rate of progress in these contexts means that the SDG target. Of 195 countries analysed in 40 of the 58 countries classified as fragile are this report, 121 already met the SDG target at risk of missing the SDG target for under-five on under-five mortality, and 21 countries are mortality by 2030. expected to do so by 2030, if current trends continue.12 Efforts to accelerate progress need Further efforts are needed to understand to be scaled up in the remaining 53 countries, uneven levels and trends in reducing under- two thirds of which are in sub-Saharan Africa, five mortality within and across countries. to reach the 2030 target (Figure 7). Of these Past analysis of under-five mortality in low- and 53 countries, 28 will need to more than double 14 FIGURE More countries are at risk of missing the neonatal mortality SDG target than the under-five 7 mortality target Projected year to achieve the SDG target in neonatal mortality and under-five mortality if current trends continue in the 82 countries that have not achieved the under-five or neonatal mortality SDG target in 2018 2100 Projected year to achieve the neonatal mortality SDG target if current trends continue Countries that will achieve the under-five mortality SDG target in time 2075 Under-five deaths (in thousands) in 2018 800 600 400 200 Sub-Saharan Africa Oceania (exc. Australia and New Zealand) Central and Southern Asia 2050 Northern Africa and Western Asia Latin America and the Caribbean Eastern and South-Eastern Asia 2030 Countries that will achieve the neonatal mortality SDG target in time 2018 2018 2030 2050 2075 2100 Projected year to achieve the under-five mortality SDG target if current trends continue Note: All calculations are based on unrounded numbers. Each bubble presents a country that in 2018 had an under-five or neonatal mortality rate above the SDG target. The size of the bubble represents the number of under-five deaths in 2018. Countries above the diagonal line are projected to achieve the under- five mortality target before they achieve the neonatal mortality target if current trends continue. Countries in the blue shaded area will meet the under-five and neonatal mortality targets by 2030. their current rate of reduction to achieve the Meeting the SDG target in the 53 countries in SDG on time. In countries that already achieved which acceleration is required would reduce the the SDG target, efforts to reduce inequity in number of under-five deaths by almost 11 (9, mortality within country should be intensified to 15) million between 2019 and 2030. Concerted achieve further reductions in preventable child and urgent action is needed in the countries deaths. that are falling behind. Even more lives could be saved, almost 29 million from 2019 to 2030, if all Accelerating progress to achieve the SDG target countries would achieve the average under-five by 2030 in countries that are falling behind mortality level in high-income countries (5 deaths would mean averting almost 11 million under- per 1,000 live births in 2018) by 2030. five deaths compared with the current scenario. On current trends,12 about 52 (49, 58) million Ending deaths of children under age 5 from children under 5 years of age will die between preventable diseases is critical. Despite advances 2019 and 2030, half of them newborns. More in fighting childhood illnesses, infectious diseases than half of these 52 million deaths will occur in remain a leading cause of death for children sub-Saharan Africa (29 (27, 35) million) and 26 under the age of 5, particularly in sub-Saharan per cent in Southern Asia (14 (12, 15) million). Africa and Southern Asia. Pneumonia (15 per 15 cent), diarrhoea (8 per cent) and malaria (5 FIGURE Infectious diseases remain a leading cause of per cent) remain among the leading causes of 8 death among children under age 5 death globally among children under age 5 – accounting for almost a third of global under- five deaths (Figure 8). Malnourished children, particularly those with severe acute malnutrition, A. Global distribution of deaths among children under age 5, by cause, 2018 have a higher risk of death from these common childhood illnesses. Nutrition-related factors Deaths among children Neonatal deaths (47%) contribute to about 45 per cent of deaths in aged 1–59 months (53%) Pneumonia,3% children under 5 years of age. Neonatal mortality Pneumonia,12% The first 28 days of life – the neonatal period Preterm birth – are the most vulnerable time for a child’s complications,16% Other,12% survival. Children face the highest risk of dying in their first month of life, at a global rate of 18 Congenital,4% Intrapartum-related events,11% Intrapartum-related (17, 19) deaths per 1,000 live births. Globally, an events,1% estimated 2.5 (2.4, 2.7) million newborns died Preterm birth complications,2% Sepsis,7% in the first month of life in 2018 – approximately Meningitis,2% 7,000 every day. Based on a recent systematic AIDS,1% Injury,6% review, about a third of all neonatal deaths tend Malaria,5% Diarrhoea, Other,3% 8% to occur on the day of birth and close to three Injury,1% Congenital,5% quarters die in the first week of life.13, 14 These Measles,2% Tetanus,1% findings suggest that focusing on the critical Diarrhoea,0.3% periods before and immediately following birth is essential to saving more newborn lives. B. Global distribution of newborn deaths by cause, 2018 Progress in reducing neonatal mortality is Pneumonia 6% Diarrhoea 1% slower than mortality in older ages and the Intrapartum-related Congenital share of neonatal deaths relative to all under- Preterm birth complications 35% complications 24% Sepsis 15% abnormalities Other 11% 7% five deaths has increased. Neonatal mortality Tetanus declined more slowly than mortality among 1% children aged 1–59 months. Globally, the Note: Estimates are rounded and therefore may not total 100 per cent. average annual rate of reduction in the neonatal Source: WHO and Maternal and Child Epidemiology Estimation Group (MCEE) interim mortality rate was 2.6 (2.3, 2.8) per cent from estimates produced in September 2019, applying cause fractions for the year 2017 to UN IGME estimates for the year 2018. 1990 to 2018 (Table 3), a smaller reduction than among children aged 1–59 months with 3.6 (3.3, 3.9) per cent. As a result, the share of neonatal deaths among all under-five deaths among SDG regions, 54 per cent of all under- increased from 40 (39, 41) per cent in 1990 to 47 five deaths occur during the neonatal period. (45, 49) per cent in 2018. Across all regions, the An exception is Southern Asia, where the annual rate of reduction from 1990 to 2018 was proportion of neonatal deaths is among the larger for children aged 1–59 months than for highest (62 per cent) despite a relatively high newborns. under-five mortality rate (Table 4). Newborn deaths often account for a larger Some countries have relatively high neonatal share of under-five deaths at lower under-five mortality given their level of under-five mortality levels. The share of neonatal deaths mortality. Based on the global relationship among under-five deaths is still relatively low in of neonatal mortality to under-five mortality sub-Saharan Africa (36 per cent), which remains observed for all countries, a few countries the region with the highest under-five mortality continue to show high, outlying levels of neonatal rate. In Europe and Northern America, which mortality given their level of under-five mortality. has one of the lowest under-five mortality rates Most of these countries are in Southern Asia. 16 Despite declining neonatal mortality levels, (1.3, 2.1) per cent annual rate of reduction in the marked disparities in neonatal mortality exist average neonatal mortality rate from 1990 to 2018 across regions and countries. Among the SDG in sub-Saharan Africa (Table 4), the number of regions, sub-Saharan Africa had the highest neonatal deaths stagnated at around 1 million neonatal mortality rate in 2018 at 28 deaths deaths per year due to an increasing number of per 1,000 live births, followed by Central and births. The number of births in the region grew Southern Asia with 25 deaths per 1,000 live births at an annual rate of 1.8 per cent from 1990 to (Table 3). A child born in sub-Saharan Africa 2018; close to half a billion births are projected to is 10 times more likely to die in the first month take place in the region from 2019–2030 (about than a child born in a high-income country. 29 per cent of global births projected over that Across countries, neonatal mortality rates ranged period).8 In 40 per cent (19) of sub-Saharan from 1 death per 1,000 live births to 42 deaths African countries, the number of neonatal deaths (Map 2). The risk of dying for a newborn in the did not decline from 1990 to 2018 even though first month of life is about 49 times higher in the rates of neonatal mortality fell over the same the highest-mortality country than in the lowest- period. Liberia and Rwanda were the two notable mortality country. countries with large reductions in the neonatal mortality rate, with an average annual rate of The number of newborn deaths has stagnated reduction of more than 3 per cent from 1990 to in sub-Saharan Africa. Despite a modest 1.8 2018. TABLE 3  Levels and trends in the neonatal mortality rate by Sustainable Development Goal region, 1990–2018 Neonatal mortality rate Decline Annual rate of reduction (deaths per 1,000 live births) (per cent) (per cent) Region 1990 1995 2000 2005 2010 2015 2018 1990–2018 1990–2018 1990–2000 2000–2018 Sub-Saharan Africa 46 44 41 36 32 29 28 39 1.8 1.1 2.1 Northern Africa and Western Asia 31 27 23 20 17 15 14 55 2.9 2.8 2.9 Northern Africa 33 30 26 23 20 17 16 52 2.6 2.3 2.8 Western Asia 28 24 20 16 14 12 11 60 3.3 3.3 3.3 Central and Southern Asia 56 51 45 39 33 27 25 56 3.0 2.2 3.4 Central Asia 28 29 27 22 18 13 12 58 3.1 0.6 4.5 Southern Asia 57 52 46 39 33 28 25 56 2.9 2.2 3.3 Eastern and South-Eastern Asia 28 25 20 15 11 9 7 73 4.7 3.1 5.6 Eastern Asia 28 25 20 13 8 5 4 85 6.7 3.3 8.6 South-Eastern Asia 28 24 21 18 16 14 13 54 2.8 2.8 2.8 Latin America and the Caribbean 23 19 16 13 11 10 9 60 3.3 3.6 3.1 Oceania 14 13 13 13 11 10 10 28 1.2 0.4 1.6 Australia and New Zealand 5 4 4 3 3 3 2 46 2.2 2.6 2.0 Oceania (exc. Australia and New Zealand) 27 26 25 24 22 21 20 28 1.2 0.8 1.4 Europe and Northern America 7 6 5 4 4 3 3 58 3.1 3.4 3.0 Europe 8 7 6 4 3 3 3 66 3.8 3.7 3.9 Northern America 6 5 5 4 4 4 3 38 1.7 2.1 1.5 Landlocked developing countries 47 45 41 36 31 27 25 48 2.3 1.4 2.9 Least developed countries 52 47 42 36 32 28 26 50 2.5 2.2 2.7 Small island developing States 27 24 23 22 22 20 19 30 1.3 1.4 1.2 World 37 34 31 26 22 19 18 52 2.6 1.8 3.0 Note: All calculations are based on unrounded numbers. 17 MAP Huge variation in the level of neonatal mortality persists across countries and regions 2 Neonatal mortality rate (deaths per 1,000 live births) by country, 2018 Neonatal mortality rate (deaths per 1,000 live births) >35 25 to 35 12 to 25 5 to 12 ≤5 No data Note: The classification is based on unrounded numbers. This map does not reflect a position by UN IGME agencies on the legal status of any country or territory or the delimitation of any frontiers. TABLE 4  Levels and trends in the number of neonatal deaths by Sustainable Development Goal region, 1990–2018 Neonatal deaths as Decline Number of neonatal deaths (thousands) a share of under-five (per cent) deaths (per cent) Region 1990 1995 2000 2005 2010 2015 2018 1990–2018 1990 2000 2018 Sub-Saharan Africa 985 1,050 1,085 1,069 1,052 1,029 1,016 -3 26 28 36 Northern Africa and Western Asia 284 246 215 193 181 168 157 45 42 47 53 Northern Africa 153 132 116 109 107 102 95 38 40 45 53 Western Asia 131 114 99 84 74 67 62 53 44 48 53 Central and Southern Asia 2,285 2,094 1,849 1,572 1,302 1,056 942 59 46 50 61 Central Asia 44 40 32 29 27 22 19 56 40 42 51 Southern Asia 2,241 2,054 1,817 1,543 1,274 1,034 922 59 46 50 62 Eastern and South-Eastern Asia 1,095 822 634 462 347 264 224 80 48 51 50 Eastern Asia 760 537 393 247 156 102 78 90 53 57 50 South-Eastern Asia 335 285 241 216 192 162 146 57 39 44 50 Latin America and the Caribbean 267 226 182 140 118 104 95 64 42 48 55 Oceania 7 7 7 8 7 7 7 8 39 42 48 Australia and New Zealand 1 1 1 1 1 1 1 35 49 55 62 Oceania (exc. Australia and New Zealand) 6 6 6 6 6 6 6 2 38 41 47 Europe and Northern America 98 75 60 53 46 41 36 63 51 54 54 Europe 74 54 41 33 28 24 21 71 51 53 54 Northern America 24 21 20 20 18 16 15 38 52 55 55 Landlocked developing countries 521 527 516 486 456 413 392 25 30 31 44 Least developed countries 1,113 1,095 1,061 993 920 852 821 26 31 32 41 Small island developing States 32 30 28 27 27 24 23 29 35 39 48 World 5,022 4,521 4,032 3,496 3,053 2,669 2,476 51 40 41 47 Note: All calculations are based on unrounded numbers. 18 More countries are at risk of missing the SDG It is critical to address the main causes of target on neonatal mortality than on under- neonatal mortality, which often differ from five mortality. On current trends, more than the causes of death for older children. Preterm 60 countries will miss the target for neonatal birth, intrapartum-related complications (birth mortality (12 deaths or fewer per 1,000 live asphyxia or lack of breathing at birth), infections births) by 2030, while 53 countries will miss the and birth defects caused most neonatal deaths target for under-five mortality (25 or fewer deaths in 2018 (Figure 8). The vast majority of newborn per 1,000 live births) (Figure 7). Accelerating deaths take place in low- and lower-middle- progress in these 60-some countries to achieve income countries. As neonatal mortality rates the SDG target on neonatal mortality would save decline in higher-income countries, causes the lives of 5 (4, 7) million newborns from 2019 to other than intrapartum-related causes and 2030. Based on current trends, 26 (24, 29) million sepsis become important to reducing neonatal newborns would die between 2019 and 2030, mortality further. Congenital anomalies and and 80 per cent of these deaths would occur in prematurity are the leading causes of neonatal Southern Asia and sub-Saharan Africa. death in higher-income countries. It is possible to improve survival and health of newborns and end With modest trends in reducing neonatal preventable stillbirths by reaching high coverage mortality in sub-Saharan Africa and high levels of neonatal mortality, many countries in the of quality antenatal care, skilled care at birth, region are at risk of missing the SDG target postnatal care for mother and baby, and care of on neonatal mortality. On current trends, 42 small and sick newborns. The high percentage of 48 countries in the region are projected to of institutional deliveries (almost 80 per cent miss the SDG neonatal mortality target by 2030. globally) offers an important opportunity for About half are projected to meet the SDG target providing essential newborn care and identifying sometime after 2050 if progress is not accelerated. and managing high-risk newborns. 19 Mortality among children aged regions reduced the probability of dying among 5−14 years children aged 5–14 years by at least half from 1990 to 2018 (Table 5 and Figure 9). At the global The risk of dying between age 5 and before level, the average annual rate of reduction was reaching the fifteenth birthday is much lower 2.7 (2.3, 2.9) per cent from 1990 to 2018, with a than for children under 5 years of age. The higher rate of reduction for children aged 5–9 probability of dying among children aged 5–14 years (3.2 per cent) than for children aged 10–14 years was 7.1 (6.8, 7.9) deaths per 1,000 children years (1.8 per cent). aged 5 years in 2018 – roughly 18 per cent of the under-five mortality rate in 2018, even though the On current trends, 9.8 (9.2, 11.3) million exposure to the risk of dying is twice as long in children aged 5–14 years will die between 2019 the 5–14 age group (Figure 2). Still, an estimated and 2030. Some 5.8 (5.4, 6.2) million of those 0.9 (0.9, 1.0) million children aged 5–14 years deaths (59 per cent) will occur among children died in 2018 – about 2,500 deaths of children in aged 5–9 years, and close to 80 per cent of the this age group every day. global deaths at age 5–14 years from 2019 to 2030 will occur in just two regions: sub-Saharan Africa The world has halved the mortality rate among (5.8 (5.3, 7.0) million) and Southern Asia (2 (1.6, children aged 5–14 years since 1990. From 1990 2.5) million). to 2018, the mortality rate in older children declined by 53 per cent, and the number of Globally, mortality rates for children aged 5–9 deaths dropped by 46 per cent from 1.7 (1.7, years are higher than for children aged 10–14 1.8) million to 0.9 (0.9, 1.0) million. Most of the years and deaths among children aged 5–9 20 FIGURE Mortality among children aged 5–14 years declined in all regions between 1990 and 2018 9 Probability of dying among children aged 5–14 years (deaths per 1,000 children aged 5 years) by Sustainable Development Goal region, 1990, 2000 and 2018 Deaths per 1,000 children aged 5 years 1990 2000 2018 50 40 40 39 38 32 30 27 27 20 18 19 14 15 13 13 13 13 11 11 12 10 10 10 8 8 7 6 7 7 6 5 4 3 3 3 2 1 2 1 1 0 Sub-Saharan Oceania Central and Northern Eastern and Latin America Europe and Australia and Landlocked Least Small island World Africa (exc. Australia Southern Africa and South-Eastern and the Northern New Zealand developing developed developing and New Zealand) Asia Western Asia Caribbean America countries countries States Asia Note: All figures are based on unrounded numbers. TABLE Levels and trends in the probability of dying and the number of deaths among children aged 5–14 years 5  by Sustainable Development Goal region, 1990–2018 Probabilty of dying among Annual Number of deaths among children children aged 5–14 years Decline rate of aged 5–14 years (deaths per 1,000 children (per cent) reduction (thousands) aged 5 years) (per cent) Region 1990 2000 2010 2015 2018 1990–2018 1990–2018 1990 2000 2010 2015 2018 Sub-Saharan Africa 40 32 23 20 18 55 2.9 575 575 528 517 510 Northern Africa and Western Asia 11 8 5 6 5 58 3.1 83 64 48 53 46 Northern Africa 13 8 6 5 5 63 3.6 48 35 26 24 23 Western Asia 9 7 5 6 4 51 2.6 35 30 22 28 23 Central and Southern Asia 19 13 9 7 6 70 4.3 605 469 330 255 219 Central Asia 7 5 4 4 3 50 2.4 8 7 4 4 5 Southern Asia 20 13 9 7 6 70 4.3 597 462 326 251 214 Eastern and South-Eastern Asia 10 7 4 4 3 66 3.9 337 234 133 109 100 Eastern Asia 7 5 3 3 2 68 4.1 169 115 57 47 43 South-Eastern Asia 15 11 7 6 5 67 4.0 169 119 76 62 57 Latin America and the Caribbean 6 4 7 3 3 52 2.7 63 48 76 33 30 Oceania 6 5 5 4 4 40 1.8 3 3 3 2 2 Australia and New Zealand 2 1 1 1 1 58 3.1 1 0 0 0 0 Oceania (exc. Australia and New Zealand) 13 11 10 9 8 42 1.9 2 2 2 2 2 Europe and Northern America 3 2 1 1 1 59 3.2 42 32 18 16 16 Europe 3 3 2 1 1 63 3.5 33 23 12 10 10 Northern America 2 2 1 1 1 45 2.2 9 8 6 6 6 Landlocked developing countries 38 27 18 15 13 64 3.7 277 254 200 181 173 Least developed countries 39 27 20 16 14 63 3.6 571 499 457 387 371 Small island developing States 13 10 41 7 7 49 2.4 13 11 47 8 8 World 15 12 9 8 7 53 2.7 1,708 1,426 1,134 985 923 Note: All calculations are based on unrounded numbers. 21 MAP Countries with the highest mortality among children aged 5–14 years are concentrated in 3 Sub-Saharan Africa Probability of dying among children aged 5–14 years (deaths per 1,000 children aged 5 years) by country, 2018 Probability of dying among children aged 5−14 years (deaths per 1,000 children aged 5 years) >30 20 to 30 10 to 20 5 to 10 1 to 5 ≤1 No data Note: The classification is based on unrounded numbers. This map does not reflect a position by UN IGME agencies on the legal status of any country or territory or the delimitation of any frontiers. years accounted for 61 per cent of all deaths Northern America and Europe. At the country of children aged 5–14 years. In low-income level, mortality ranged from 0.4 to 37.3 deaths countries, with an average mortality rate among per 1,000 children aged 5 years. The higher children aged 5–14 years of 16.6 (15.3, 19.3) mortality countries are concentrated in sub- deaths per 1,000 children aged 5 years, about two Saharan Africa (Map 3) and all 14 countries thirds of deaths happened in the 5–9 age group, with a mortality rate for children aged 5–14 while in high-income countries, with an average years above 20 deaths per 1,000 children aged 5 rate of 1.1 (1.1, 1.2) deaths, less than half of the years in 2018 are in sub-Saharan Africa. deaths among 5- to 14-year-olds occurred at ages 5–9. Injuries are a leading cause of death among older children and adolescents. Infectious Survival chances for children and young diseases of childhood such as pneumonia, adolescents are uneven across the world. In sub- diarrhoea and measles have declined since 2000 Saharan Africa, the probability of dying among for older children and young adolescents, but children aged 5–14 years in 2018 was 17.9 deaths injuries have not. In fact, injuries (including per 1,000 children aged 5 years, followed by road traffic injuries, drowning, burns, and falls) Oceania (excluding Australia and New Zealand) rank among the top causes of death and lifelong with 7.8 deaths and Central and Southern Asia disability among children aged 5–14 years. The with 5.8. More than half (55 per cent) of deaths patterns of death in older children and young among children aged 5–14 years occurred in adolescents reflect the underlying risk profiles of sub-Saharan Africa, followed by Southern Asia the age groups, with a shift away from infectious with about 24 per cent. The average risk of dying diseases of childhood and towards accidents between the fifth and fifteenth birthday was and injuries, notably drowning and road traffic 14 times higher in sub-Saharan Africa than in injuries for older children and young adolescents. 22 Conclusion Every child’s death is a tragedy: As the numbers Despite the progress, the unfinished business show, the world is suffering this tragedy at of ending preventable child deaths looms large. enormous scale. Every single day of 2018, the world If current trends continue without acceleration, saw, on average, 15,000 deaths of children under some 52 (49, 58) million children under 5 years age 5 – including 7,000 newborn deaths – and of age will die from 2019 to 2030. About half 2,500 deaths of children and young adolescents of them will be newborns. Another 10 million between age 5 and 14. Most of these deaths were children aged 5–14 years will die. The total due to preventable and treatable causes. number of 62 million deaths of children under age 15 is roughly equivalent to the current The good news is that concerted actions have led to population of Italy (Figure 10). dramatic reductions in child mortality over the past few decades – global rates of child mortality and While the global burden of child deaths the global burden of child deaths are at historic remains high, children’s chances of survival vary lows. This progress has been achieved in a world dramatically across regions and countries. For beset by natural disasters, wracked by violence many children, where they are born and live and conflict, and confronted with the scourge of determines their access to quality, affordable epidemics.15 Success in the face of such challenges health care. Too many newborns and children reflects the dedicated work of women, families, continue to die from easily preventable and health workers, communities, governments and treatable causes, because the world has failed to others across the globe to save children’s lives. ensure their basic right to survival and health. 23 FIGURE If current trends continue, four out of five child deaths under age 15 will occur in Sub-Saharan 10 Africa and Central and Southern Asia in 2019–2030 Cumulative number of projected deaths (in millions) among children under age 15 from 2019–2030 by age group and Sustainable Development Goal region Neonatal deaths Deaths among children aged 1−59 months Deaths among children aged 5−14 years Sub-Saharan Africa 35.1 Central and Southern Asia 15.9 Eastern and South-Eastern Asia 4.8 Northern Africa and Western Asia 3.4 Latin America and the Caribbean 1.8 Europe and Northern America 0.8 Oceania (exc. Australia and New Zealand) 0.2 Australia and New Zealand 0.02 0 10 20 30 40 Deaths (in millions) Note: All calculations are based on unrounded numbers. Special attention is needed for sub-Saharan Despite this unnecessary loss of life, major Africa, where child mortality rates are the highest progress is being made in many of the places that in the world while population growth continues need it most, even in some low-income countries at a rapid pace. In that region, 1 in 13 children with limited resources. Among low-income die before their fifth birthday, a substantially countries, Eritrea, Ethiopia, Liberia, Malawi, higher risk of death than in Europe, where Mozambique, Nepal, Niger, Rwanda, Uganda and just 1 in 196 children die under age 5. The Tanzania saw at least a two thirds reduction in the region is also expected to experience increasing under-five mortality rate in 1990–2018. In Nepal population, with 483 million births projected in and Rwanda, the neonatal mortality rate declined 2019–2030, an increase of 76 million births over by 60 per cent over the same period. These statistics provide a clear message: With the right the preceding period of the same length. The commitments, concerted efforts and political will, under-five population is predicted to swell to bold and ambitious goals are within reach. roughly 199 million by 2030, from 166 million in 2018. The number of women of reproductive age Accelerating the reduction in child mortality is will also increase to 349 million from 248 million possible by expanding high-impact preventative during the same period.8 and curative interventions that target the main causes of child deaths and the most vulnerable The rapid growth in births and population population. Pneumonia-related deaths have requires additional efforts and investments to fallen, thanks to the rapid roll-out of vaccines, scale up high-impact maternal, newborn and better nutrition and improved care-seeking child survival interventions, to strengthen the behaviour and treatment for symptoms of health systems that deliver them and to meet pneumonia, among other measures.15 Diarrhoea- other needs that contribute to child survival. related deaths have declined in large part due Without accelerated progress to prevent child to improvements in drinking water, sanitation deaths, 29 million children under age 5 and 6 and hygiene, the roll-out of a rotavirus vaccine million children aged 5–14 years will die from and widespread access to and use of treatment 2019 to 2030 in sub-Saharan Africa (Figure 10). with oral rehydration salts solutions and zinc. 24 Prevention, treatment and elimination efforts quality and equity of care in the antenatal period; have averted millions of under-five deaths from care at birth and in the first week of life; and malaria. However, globally, pneumonia, diarrhoea care for small and sick newborns, which gives a and malaria remain the leading causes of death triple return on investment by saving maternal for children under age 5. Injuries play a more and newborn lives and preventing stillbirths and prominent role in the deaths of older children disability.16 Securing national-level priority for and young adolescents. Expanding inexpensive newborn health and survival and implementation and cost-effective prevention and quality of the Every Newborn Action Plan,16 the UNICEF- treatment for these causes will improve child WHO-led evidence-based action plan to prevent survival. newborn deaths and stillbirths, are critical to accomplishing the unfinished global agenda for Greater attention to saving newborn lives can newborns. accelerate reductions in the under-five deaths burden. As an increasing share of under-five To attain the SDG targets and give every child a deaths occurs during the neonatal period, a fair chance to survive, we must urgently address focus on a healthy start to life becomes even persistent disparities in maternal and child health more critical. In Southern Asia, where the ratio and ensure universal access to basic services. of neonatal mortality to under-five mortality Efforts and investment must be intensified to is high given the level of under-five mortality, reach the most vulnerable countries, communities interventions to save newborn lives should yield and children. The numbers presented in this substantial gains. To accelerate progress, greater report serve as stark reminder of the progress that investment is needed in building stronger health has been made – and the work that remains – in systems and services and improving coverage, safeguarding every child’s right to survive. Country consultation In accordance with the decision by the children under age 5 and mortality among Statistical Commission and the United children aged 5–14 years for its country. The Nations Economic and Social Council objective was to identify relevant data that resolution 2006/6, UN IGME child mortality were not included in the UN IGME database estimates, which are used for the compilation and to allow countries to review and provide of global indicators for SDG monitoring, are feedback on estimates. In 2019, 115 of 195 produced in consultation with countries. countries sent comments or additional data. UNICEF and WHO undertook joint After the consultations, the UN IGME draft country consultations in 2019. The country estimates for mortality in children under age consultation process gave each country’s 5 were revised for 92 countries using new data, ministry of health, national statistics office and the estimates for mortality in children or relevant agency the opportunity to review under age 5–14 were revised for 82 countries all data inputs, the estimation methodology due to new data. All countries were informed and the draft estimates for mortality in about changes in their estimates. 25 Estimating Child Mortality This chapter summarizes the methods UN IGME and United Nations Population Division of the uses to generate child mortality estimates for Department of Economic and Social Affairs. It children under age 5 and children aged 5–14 was established in 2004 to advance the work on years. monitoring progress towards the achievement of child survival goals. Its Technical Advisory Group UN IGME updates its estimates of neonatal, (TAG), comprising leading academic scholars infant, under-five mortality and mortality among and independent experts in demography and children aged 5–14 years annually after reviewing biostatistics, provides guidance on estimation newly available data and assessing their quality. methods, technical issues and strategies for data These estimates are widely used in UNICEF’s analysis and data quality assessment. flagship publications, the United Nations Secretary-General’s annual SDG report, and Overview publications by other United Nations agencies, UN IGME follows the following broad strategy to governments and donors. arrive at annual estimates of child mortality: UN IGME is led by UNICEF and includes 1. Compile and assess the quality of all available members from WHO, the World Bank Group nationally representative data relevant to the 26 estimation of child mortality, including data from if the empirical data are of good quality. UN vital registration systems, population censuses, IGME aims to minimize errors for each estimate, household surveys and sample registration systems harmonize trends over time, and produce up- to-date and properly assessed estimates of child 2. Assess data quality, recalculate data inputs and mortality. Because errors are inevitable in data, make adjustments as needed by applying standard there will always be uncertainty around data and methods estimates, both nationally and internationally. To allow for added comparability, UN IGME 3. Fit a statistical model to these data to generate generates all child mortality estimates with a smooth trend curve that averages possibly uncertainty bounds. disparate estimates from the different data sources for a country Data sources Nationally representative estimates of under-five 4. Extrapolate the model to a target year (in this mortality can be derived from several different case, 2018) sources, including civil registration and sample surveys. Demographic surveillance sites and To increase the transparency of the estimation hospital data are excluded as they are rarely process, UN IGME has developed a Child representative. The preferred source of data is a Mortality Estimation (CME) web portal, available civil registration system that records births and at . It includes all deaths on a continuous basis. If registration is available data and shows estimates for each complete and this system functions efficiently, the country, as well as which data are currently resulting estimates will be accurate and timely. officially used by UN IGME. Once new estimates However, many low- and middle-income countries are finalized, the CME web portal is updated do not have well-functioning vital registration accordingly. systems, and household surveys, such as the UNICEF-supported Multiple Indicator Cluster UN IGME applies a common methodology across Surveys, the USAID-supported Demographic and countries and uses original empirical data from Health Surveys, and periodic population censuses each country but does not report figures produced have become the primary sources of data on by individual countries using other methods, mortality among children under age 5 and aged which would not be comparable to other country 5–14 years. These surveys ask women about the estimates. Applying a consistent methodology survival of their children, and it is these reports allows for comparisons between countries, despite (or microdata upon availability) that provide the the varied number and types of data sources. basis of child mortality estimates for a majority of low- and middle-income countries. UN IGME estimates are based on nationally available data from censuses, surveys or vital The first step in the process of arriving at registration systems. UN IGME does not use estimates of levels and recent trends of child covariates to derive its estimates, but rather mortality is to compile all newly available data applies a curve fitting method to empirical data and add the data to the UN IGME database. after data quality assessment. Countries often Newly available data will include recently released use a single source for their official estimates vital statistics from a civil registration system, or apply methods different to those used by UN results from recent censuses and household IGME. The differences between UN IGME and surveys and, occasionally, results from older national official estimates are usually not large censuses or surveys not previously available. 27 The full set of empirical data used in this a standard period abridged life table using the analysis is publicly available from the UN IGME age-specific deaths and midyear population web portal, at . In counts from civil registration data. The neonatal this round of estimation, a substantial amount mortality rate (NMR, the probability of dying in of newly available data has been added to the the first 28 days of life, expressed per 1,000 live underlying database for under-five, infant and births) is calculated with the number of deaths of neonatal mortality. Data from 40 new surveys infants under one month of age and the number or censuses were added for 36 countries and of live births in a given year. data from vital registration systems or sample vital registration systems were updated for 133 For civil registration data (with available data on countries. In total, more than 1,500 country-year the number of deaths and midyear populations), data points from about 300 series were added annual observations were initially constructed for or updated. The database, as of August 2019, all observation years in a country. For country- contains over 20,000 country-year data points years in which the coefficient of variation from more than 1,600 series across 195 countries exceeded 10 per cent for children under 5 years from 1990 (or earlier, back to 1940) to 2018. For or 20 per cent for children aged 5–14 years, mortality among children aged 5–14 years, data deaths and midyear populations were pooled were calculated from censuses and surveys or vital over longer periods, starting from more recent registration records of population and deaths in years and combining those with adjacent previous the age group. The database for mortality among years, to reduce spurious fluctuations in countries children aged 5–14 years contains more than where small numbers of births and deaths were 6,600 data points. observed. The coefficient of variation is defined to be the stochastic standard error of the 5q0 The increased empirical data have substantially (5q0 =U5MR/1,000) or 1q0 (1q0 =IMR/1,000) changed the UN IGME estimates for some observation divided by the value of the 5q0 or countries from previous editions partly because 1q0 observation. The stochastic standard error the fitted trend line is based on the entire time of the observation is calculated using a Poisson series of data available for each country. The approximation using live birth numbers, given estimates presented in this report may differ from by sqrt(5q0/lb) (or similarly sqrt(1q0/lb), where and are not necessarily comparable with previous lb is the number of live births in the year of the sets of UN IGME estimates or the most recent observation.18 After this recalculation of the civil underlying country data. registration data, the standard errors are set to a minimum of 2.5 per cent for input into the Whatever the method used to derive the model. A similar approach was used for neonatal estimates, data quality is critical. UN IGME mortality and mortality among children aged assesses data quality and does not include data 5–14 years. sources with substantial non-sampling errors or omissions as underlying empirical data in its In previous revisions, UN IGME adjusted statistical model. vital registration data for incompleteness in the reporting of early infant deaths in several Civil registration data European countries. For more details on the past Data from civil registration systems are the adjustment, see Notes.19 preferred data source for child mortality estimation. The calculation of under-five Survey data mortality rates (U5MR, the probability of The majority of survey data on child mortality dying between birth and exactly 5 years of age, comes in one of two forms: the full birth history expressed per 1,000 live births), infant mortality (FBH), whereby women are asked for the date rates (IMR, the probability of dying between birth of birth of each of their children, whether the and exactly one year of age, expressed per 1,000 child is still alive, and if not, the age at death; live births) and mortality rates among children and the summary birth history (SBH), whereby aged 5–14 years (the probability a five-year-old women are asked only about the number of their would die before reaching age 15, expressed per children ever born and the number that have 1,000 children aged 5 years) are derived from died (or equivalently the number still alive). 28 FBH data, collected by all Demographic and since first birth worthwhile when compared to the Health Surveys and increasingly by Multiple estimates derived from the classification by age Indicator Cluster Surveys and other nationally of mother, hence in cases where the microdata representative surveys, allow for the calculation of are available, the UN IGME has reanalysed the child mortality indicators for specific time periods data using the new method. Due to known biases in the past. This allows these survey programmes in the estimation for 0–4 year period by time to publish under-five child mortality estimates since first birth and for the 15–19 and 20–24 age for three 5-year periods before the survey, that is, groups of women, these data points are excluded 0 to 4, 5 to 9, 10 to 14, etc.20, 21, 22 UN IGME has in the estimation model. recalculated estimates for calendar year periods, using single calendar years for periods shortly Moreover, following advice from UN IGME’s before the survey, and then gradually increasing TAG, child mortality estimates from SBH were the number of years for periods further in the not included if estimates from FBH in the same past, whenever microdata from the survey is survey were available.24 SBH data are not used available. The cut-off points for a given survey for to derive neonatal mortality or mortality among shifting from estimates for single calendar years children aged 5–14 years. to two years, or two years to three, etc., are based on the coefficients of variation of the estimates.23 Adjustment for missing mothers in high-HIV settings Mortality estimates of children aged 5–14 years In populations severely affected by HIV/AIDS, can also be derived from the FBH module, but HIV-positive children will be more likely to die the probability of dying among children in this than other children and will also be less likely age group (10q5) is estimated for the period 0–12 to be reported since their mothers will also have years before the survey and divided into periods been more likely to die. Child mortality estimates according to the coefficient of variation of the will thus be biased downwards. The magnitude estimates (< 20 per cent). of the bias will depend on the extent to which the elevated under-five mortality of HIV-positive In general, SBH data, collected by censuses children is not reported because of the deaths and many household surveys, use the age of the of their mothers. The TAG developed a method woman as an indicator of the age of her children to adjust HIV/AIDS-related mortality for each and their exposure time to the risk of dying, and survey data observation from FBH during HIV/ employ models to estimate mortality indicators AIDS epidemics (1980–present) by adopting for periods in the past for women ages 25 to 29 a set of simplified but reasonable assumptions through ages 45 to 49. This method is well known about the distribution of births to HIV-positive but has several shortcomings. Starting with the women, primarily relating to the duration of 2014 round of estimation, the UN IGME changed their infection, vertical transmission rates, and the method of estimation for SBHs to one based survival times of both mothers and children from on classification of women by the time that has the time of the birth.25 This method was applied passed since their first birth. This method has to all direct estimates from FBHs. No adjustment several benefits over the previous one. First, it was included for HIV-related biases in the 5–14 generally has lower sampling errors. Second, age group, since no method currently exists it avoids the problematic assumption that the to estimate the magnitude of this bias in the mortality estimates derived for each age group probability 10q5. of women adequately represent the mortality of the whole population. As a result, it has less Systematic and random measurement error susceptibility to the selection effect of young Data from these different sources require women who give birth early, since all women different calculation methods and may suffer who give birth necessarily must have a first birth from different errors, such as random errors and therefore are not selected for. Third, the in sample surveys or systematic errors due to method tends to show less fluctuation across misreporting. Thus, different surveys often time, particularly in countries with relatively low yield widely different estimates of U5MR for fertility and mortality. The UN IGME considers a given time period, as illustrated in Figure the improvements in the estimates based on time 11. In order to reconcile these differences and 29 take better account of the systematic biases between an observation and the truth with error associated with the various types of data inputs, multiplier equal to 1 (and log(error multiplier) the TAG developed an estimation method to fit equal to zero) meaning no error. a smoothed trend curve to a set of observations and to extrapolate that trend to a defined While estimating the true U5MR, properties of time point, in this case, 2018. This method is the errors that provide information about the described in the following section. quality of the observation, or in other words, the extent of error that we expect, are taken into Estimation of under-five mortality rates account. These properties include: the standard Estimation and projection of under-five mortality error of the observation, its source type (e.g., rates was undertaken using the Bayesian B-splines Demographic and Health Surveys versus census) bias-adjusted model, referred to as the B3 model. and whether the observation is part of a data This model was developed, validated and used series from a specific survey (and how far the data series is from other series with overlapping to produce the previous rounds of the UN IGME observation periods). These properties are child mortality estimates, including the previously summarized in the so-called data model. When published round in September 2018.26, 27 estimating the U5MR, the data model adjusts for errors in observations, including the average In the B3 model, log(U5MR) is estimated systematic biases associated with different types with a flexible splines regression model. The of data sources, using information on data quality spline regression model is fitted to all U5MR for different source types from all countries. observations in the country. An observed value for U5MR is considered to be the true value for U5MR multiplied by an error multiplier, i.e., Figure 12 displays the U5MR over time for observed U5MR = true U5MR * error multiplier, Senegal, used here for illustrative purposes. or on the log scale, log(observed U5MR) = log(true U5MR) + log(error multiplier). The Compared with the previously applied Loess error multiplier refers to the relative difference estimation approach, the B3 model better FIGURE 11 Empirical child mortality data in Nigeria and Papua New Guinea Nigeria Papua New Guinea Under-five mortality rate (deaths per 1,000 live births) Neonatal mortality rate (deaths per 1,000 live births) 350 60 ● 300 ● ● ● ● ● ● 50 ● 250 ● ● ● ● ● ● ● ● ● ●● ●● ● ● ● ●●●● ● ● ● ● ● ● ● ●● ● ●●● ● ●●● ● ● ● ● 40 200 ● ● ●● ● ● ● ● ● ● ● ● ● ● ● ●● ● ●● ● ● ● ● ● ● ● ●●● ● ●● ● ●●● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ●● ● ● ● ●●● ●● ● ● ● ● ● ● ● ● ● 30 ● ● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ●● ● 150 ● ● ● ●● ●● ● ● ● ● ● ● ● ● ●●● ●●●● ●● ● ● ●●● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ●●● ● ●● ● ● ● ● ● ● ● ●●● ● ● ●● 20 ● ● 100 ● ● ● ● 50 10 ● 0 0 1960 1970 1980 1990 2000 2010 2020 1980 1990 2000 2010 Year Year Note: All data available for the country are shown as coloured points, with observations from the same data series joined by lines, and each colour identifying different data sources. Grey bands in the left plot represent the standard errors of the observations where available or applicable. Filled points and solid lines represent data series/ observations that were included in the statistical model. 30 accounts for data errors, including biases and is the ratio of the IMR estimate to the median B3 sampling and non-sampling errors in the data. estimate of U5MR in the corresponding country- It can more accurately capture short-term year. This is to restrict the IMR estimate to be fluctuations in the U5MR and its annual rate lower than the U5MR estimate for any given year. of reduction, and thus is better able to account For the remaining countries, the IMR is derived for evidence of acceleration in the decline of from the U5MR, through the use of model life under-five mortality from new surveys. Validation tables that contain known regularities in age exercises show that the B3 model also performs patterns of child mortality.28 The advantage better in short-term projections. of this approach is that it avoids potential problems with the underreporting of neonatal The B3 method was developed and implemented deaths in some countries and ensures that the for the UN IGME by Leontine Alkema and internal relationships of the three indicators are Jin Rou New with guidance and review by the consistent with established norms. For Sahelian UN IGME’s TAG. A more complete technical countries (Burkina Faso, Chad, the Gambia, description of the B3 model is available Mali, Mauritania, the Niger and Senegal), the elsewhere.18 relationship from model life tables does not apply between infant and child mortality, thus a logit Estimation of infant mortality rates transform of the ratio of IMR/U5MR is used to In general, the B3 model described above is estimate IMR from U5MR using data from FBHs applied to the U5MR for all countries (except and a multilevel regression with country-specific for the Democratic People’s Republic of Korea, intercept. where a non-standard method was employed). For countries with high-quality vital registration data (covering a sufficient period of time and Adjustment for rapidly changing child deemed to have high levels of completeness and mortality driven by HIV/AIDS coverage), the B3 model is also used, but is fitted To capture the extraordinarily rapid changes to the logit transform of r, i.e., log(r/1-r), where r in child mortality driven by HIV/AIDS over the epidemic period in some countries, the regression models were fitted to data points for FIGURE the U5MR from all causes other than HIV/AIDS, Empirical under-five mortality data and 12 estimates from the B3 model for Senegal and then UNAIDS estimates of HIV/AIDS under- five mortality were added to estimates from the regression model. This method was used for 17 countries where the HIV prevalence rate Senegal Under-five mortality rate (deaths per 1,000 live births) exceeded 5 per cent at any point in time since 500 1980. Steps were as follows: 400 ● ● 1. Compile and assess the quality of all newly available nationally representative data relevant to ● ● ● ● ● ●● ● 300 ● ● ● ● ● ● the estimation of child mortality ●● ● ●● ● ● ● ● ● ● ● ●●● ● ● ● ● ●● ●● ●●● ●● ● ●● ● ● ● ● ●● ● ●● ●● ●●● ● ● ● ● ● ● ● ●●● ● ● 200 ●●● ●●●● 2. Adjust survey data to account for possible ● ●● ●●●● ● ● ●● ●●●●● ●● ● ● ● ●●● ● ● ●● ●●● ● ●● ● ● ● ● biases in data collection and in HIV/AIDS ● ●●●● ●●● ● ● ● ●● ●●●●● ● ● ●●● ● ● ●● ● ●●● ●● ● ●●●●●● ●● ●●●●● ●●●● ● ● ● ●● ●● ● ●●●● ● ● ● ● ● ● ● ● ●● ●● ● ● ● ●●●● 100 ●●●● ● ● epidemic ● ●● ● ● ● ● ●● ●●●● ●●● ● ● ●●●●● ● ●● ● ● ● ● ● ● ●●●● ●● ● ● ●● 0 3. Use UNAIDS estimates of HIV/AIDS child 1960 1980 2000 2020 mortality29 to adjust the data points from 1980 Year onwards to exclude HIV/AIDS deaths Note: The B3 estimates are in red. Ninety per cent uncertainty intervals for the U5MR are given by the pink bands. All data available for the country are shown as coloured points, with observations from the same data 4. Fit the standard statistical model to the series joined by lines. Filled points and solid lines represent data series/ observations that were included for curve-fitting. Grey bands represent the observations to HIV-free data points standard errors of the observations where available or applicable. 31 5. Extrapolate the model to the target year; in Estimation of mortality rates among this case, 2018 children aged 5–14 years Since 2017, UN IGME has generated country- 6. Add back estimates of deaths due to HIV/AIDS specific trend estimates of the mortality in (from UNAIDS) children aged 5–14 years – that is, the probability that a child aged 5 years dies before reaching 7. Derive a non-AIDS curve of IMR from the his or her fifteenth birthday (10q5). The methods estimated U5MR using model life tables; add used are similar to those used to estimate the the UNAIDS estimates of HIV/AIDS deaths for U5MR. The B3 statistical model developed for children under age 1 to generate the final IMR under-five mortality was used to obtain a smooth estimates trend curve in 10q5 as well. In 33 countries, there were not enough data inputs to estimate the Estimation of under-five and infant probability 10q5 from vital registration, surveys mortality rates by sex or censuses. For these cases, the probability 10q5 In 2012, the UN IGME produced estimates of was modelled on the draft estimates of U5MR, U5MR for males and females separately for the and an expected relation between mortality in first time.30 In many countries, fewer sources the 0–4 and 5–14 age groups, as observed in have provided data by sex than for both sexes countries with sufficient data series. A linear combined. For this reason, the UN IGME, rather regression was used to regress log(10q5) against than estimate U5MR trends by sex directly from log(U5MR), with region-specific dummies, and reported mortality levels by sex, uses the available the coefficients of this regression were used to data by sex to estimate a time trend in the sex predict the probability 10q5 between 1990 and ratio (male/female ratio) of U5MR instead. 2018 for countries with insufficient data sources. Bayesian methods for the UN IGME estimation The advantage of this approach is that no model life tables are used (such life tables are based on of sex ratios with a focus on the estimation and the historical experience of countries with high- identification of countries with outlying levels quality vital registration data and do not always or trends were used. A more complete technical adequately reflect mortality age patterns in low- description of the model is available elsewhere.31 and middle-income countries). A more complete technical description of the model is available Estimation of neonatal mortality rates elsewhere.33 The NMR is defined as the probability of dying before 28 days, per 1,000 live births. In 2015, No adjustment was included for HIV-related the UN IGME method for estimating NMR biases in the 5–14 age group, since no method was updated. The new Bayesian methodology currently exists to estimate the magnitude of this is similar to that used to estimate U5MR and bias in the probability 10q5. This bias should be derive estimates by sex. It has the advantage that, less severe when estimating mortality in the 5–14 compared to the previous model, it can capture age group as compared with the U5MR, because data-driven trends in NMR within countries and in the absence of treatment, the majority of over time for all countries. A more complete children infected through their mothers will die technical description of the model is available before reaching age 5. elsewhere.32 Estimation of child mortality due to For neonatal mortality in HIV-affected and conflict and natural disasters crisis-affected populations, the ratio is estimated Estimated deaths for major crises were derived initially for non-AIDS and non-crisis mortality. from various data sources from 1990 to present. After estimation, crisis neonatal deaths are added Natural disasters were obtained from the Centre back on to the neonatal deaths to compute the for Research on the Epidemiology of Disasters’ total estimated neonatal mortality rate. No AIDS International Disaster Database,34 with under-five deaths are added to the NMR, thereby assuming proportions estimated as described elsewhere,35 these deaths only affect child mortality after the and conflict deaths were taken from Uppsala first month of life. Conflict Data Program/Peace Research Institute 32 Oslo data sets as well as reports prepared by the more conventional 95 per cent intervals. While UN and other organizations. Estimated child reporting intervals based on higher levels of deaths due to major crises were included if they uncertainty (i.e., 95 per cent instead of 90 per met the following criteria: (1) the crisis was cent) would have the advantage that the chance isolated to a few years; (2) under-five crisis deaths of not having included the true value in the or crisis deaths among children aged 5–14 years interval is smaller, the disadvantage of choosing were greater than 10 per cent of non-crisis deaths higher uncertainty levels is that intervals lose in the age group; (3) crisis U5MR or crisis 10q5 was their utility to present meaningful summaries > 0.2 deaths per 1,000; (4) the number of crisis of a range of likely outcomes if the indicator of deaths among children under 5 years or among interest is highly uncertain. Given this trade- those 5–14 years old was > 10 deaths. off and the substantial uncertainty associated with child mortality estimates, UN IGME chose These criteria resulted in 18 different crises to report 90 per cent uncertainty intervals, or, being explicitly incorporated into the UN IGME in other words, intervals for which there is a 90 estimates for under-five mortality and 42 different per cent chance that they contain the true value, crises being incorporated into the mortality to encourage wider use and interpretation of estimates among children aged 5–14 years. uncertainty intervals. Because the background mortality rates were relatively low in the 5–14 age group, crisis deaths Extrapolation to common reference year represented a larger share of deaths, and thus If the underlying empirical data refer to an more crises met these criteria than for under- earlier reference period than the end year of the five mortality. Crisis deaths were included in the period the estimates are reported, UN IGME estimates by first excluding data points from crisis extrapolates the estimates to the common end years, fitting the B3 model to the remaining data, year, in this round to 2018. UN IGME does not and then adding the crisis-specific mortality rate use covariates to derive the estimates but uses to the fitted B3 curve. Crisis death estimates are the past trend in a country and the global trend uncertain, but presently no uncertainty around to extrapolate to the target year. The average crisis deaths is included in the uncertainty extrapolation period in the 2019 round of intervals of the estimates. Instead, we assume estimation was 4.7 years for under-five mortality, the relative uncertainty in the adjusted estimates with half of the countries having data points is equal to the relative uncertainty in the non- within the past 3.1 years. For more than a third of adjusted estimates; this assumption will be all countries, the latest available child mortality revisited in the near future. data point was more than five years old (Figure 13). UN IGME has assessed recent crises and, based on the scarcity of currently available data and the Calculating number of deaths difficulties of estimating the broader impact of Under-five, infant and neonatal deaths these crises on health systems, decided to hold the A birth-week cohort method is used to calculate estimates constant from the start of the crisis while the absolute number of deaths among neonates, increasing the uncertainty over the crisis time infants and children under age 5. First, each for four countries: South Sudan, the Syrian Arab annual birth cohort is divided into 52 equal Republic, Venezuela (Bolivarian Republic of) and birth-week cohorts. Then each birth-week cohort Yemen. Where applicable, direct crisis deaths have is exposed throughout the first five years of been added to the constant trend estimate. UN life to the appropriate calendar year- and age- IGME will review new data, if available, in the next specific mortality rates depending on cohort age. estimation round and revise estimates accordingly. For example, the twentieth birth-week cohort of the year 2000 will be exposed to the infant mortality rates in both 2000 and 2001. All deaths Estimation of uncertainty intervals from birth-week cohorts occurring as a result Given the inherent uncertainty in child mortality estimates, 90 per cent uncertainty of exposure to the mortality rate for a given intervals are used by UN IGME instead of the calendar year are allocated to that year and are 33 FIGURE Distribution of the country extrapolation periods in each Sustainable Development Goal region and 13 the world Per cent Australia and New Zealand, Europe ≤2 years 74% 22% 4% and Northern America 2–5 years Northern Africa and Western Asia 50% 25% 13% 13% 5–10 years >10 years Eastern and South-Eastern Asia 44% 25% 19% 13% Central and Southern Asia 36% 43% 14% 7% Latin America and the Caribbean 30% 27% 27% 15% Sub-Saharan Africa 8% 40% 35% 17% Oceania (exc. Australia and New Zealand) 7% 7% 43% 43% World 37% 28% 22% 13% summed by age group at death to get the total Prospects 20198 is used to calculate the number number of deaths for a given year and age group. of deaths. Continuing with the above example, deaths from the twentieth birth-week cohort of the year 2000 Deaths among children aged 5–14 years would contribute to infant deaths in year 2000 The absolute number of deaths among children and 2001. Any deaths occurring among the aged 5–14 years in a given year and country twentieth birth-week cohort of year 2000 after is calculated using the central death rates for the twentieth week in 2001 would contribute the 5–9 and 10–14 age groups, 5M9 and 10M14, to under-five deaths for year 2001 and so forth. computed from the estimated 5q5 and 5q10 using a Under-five deaths in each calendar year are standard period abridged life table. The central calculated by summing up all the deaths under death rates are then multiplied by the country age 5 across all age group cohorts in that year. population estimates for the respective age The annual estimate of the number of live births groups from the World Population Prospects in each country from the World Population 20198 to calculate the number of deaths. 34 Notes The UN IGME previously carried out an analysis of the ratio of early 1. Values in parentheses indicate 90 per cent uncertainty intervals for the neonatal (under seven days) deaths to total neonatal deaths, which estimates. showed that several countries, many in Eastern Europe, had significantly lower values than what would be expected, suggesting an undercounting 2. United Nations, Convention on the Rights of the Child, Treaty Series, of early infant deaths. The results of this analysis were used as an vol. 1577, 1989, p. 3. upwards adjustment of 10 per cent or 20 per cent to under-five mortality rates across all years for several countries in previous UN IGME reports. 3. Every Woman Every Child, The Global Strategy for Women’s, Children’s and Adolescents’ Health (2016–2030), , accessed the latest data, and the clear signal of underreporting was no longer 3 September 2019. apparent across countries. Therefore, the UN IGME has removed these adjustment factors in the estimates for this publication. Going 4. See . forward, the UN IGME will assemble finer age-specific child mortality 5. These estimates supersede previously published estimates. Differences data and attempt to determine the current level of underreporting with previously published estimates should not be interpreted as bias in different countries, and how that bias has changed over time. representing time trends. This analysis could lead to a different adjustment approach in future estimates. 6. The annual rate of reduction (ARR) in the mortality rates is defined as ARR=log(Mortality ratet2/Mortality ratet1) / (t1 – t 2) where t1 and t 2 refer 20. United Nations Children’s Fund, MICS6 Tools, UNICEF, New York, to different years with t1< t 2. 2018, . 7. All references to regions in this report are based on the Sustainable 21. United States Agency for International Development, Guide to Development Goal regional classification. See . Calverton, Maryland, September 2006. 8. United Nations Department of Economic and Social Affairs 22. Hill, Kenneth, ‘Child Mortality’, ch. 15 in Tools for Demographic Population Division, World Population Prospects 2019, United Nations, Estimation , edited by Tom Moultrie, et al., International Union for the New York, 2019. Scientific Study of Population, Paris, 2013, . 9. Fragility is defined as the combination of exposure to risk and insufficient coping capacity of the state, system and/or communities 23. Pedersen, Jon, and Jing Liu, ‘Child Mortality Estimation: Appropriate to manage, absorb or mitigate those risks. Fragility can lead to time periods for child mortality estimates from full birth histories’, PLoS negative outcomes including violence, the breakdown of institutions, Medicine , vol. 9, no. 8, 2012. displacement, humanitarian crises or other emergencies (Organisation 24. Silva, Romesh, ‘Child Mortality Estimation: Consistency of under- for Economic Co-operation and Development, (2016), States of Fragility five mortality rate estimates using full birth histories and summary birth 2016: Understanding Violence, p.22, OECD Publishing, Paris, https:// histories’, PLoS Medicine , vol. 9, no. 8, 2012. doi.org/10.1787/9789264267213-en.). 25. Walker, Neff, Kenneth Hill and Fengmin Zhao, ‘Child Mortality 10. Chao, Fengqing, et al., ‘National and Regional Under-5 Mortality Estimation: Methods used to adjust for bias due to AIDS in estimating Rate by Economic Status for Low-income and Middle-income Countries: trends in under-five mortality’, PLoS Medicine , vol. 9, no. 8, 2012. A systematic assessment’, The Lancet Global Health , vol. 6, no. 5, 1 May 2018. 26. United Nations Inter-agency Group for Child Mortality Estimation, Levels & Trends in Child Mortality, UNICEF, New York, 2018. 11. Li, Zehang, et al., with support from the United Nations Inter-agency Group for Child Mortality Estimation and its Technical Advisory Group, 27. See . ‘Changes in the Spatial Distribution of the Under-Five Mortality Rate: Small-area analysis of 122 DHS surveys in 262 subregions of 35 countries 28. Guillot, Michel, et al., ‘Child Mortality Estimation: A global overview in Africa’, PLoS One , vol. 14, no. 1, 22 January 2019. of infant and child mortality age patterns in light of new empirical data’, PLoS Medicine , vol. 9, no. 8, 2012. 12. The annual rate of reduction (ARR) from 2000–2018 is used to project mortality rates at the country level from 2019–2030, with the 29. Joint United Nations Programme on HIV/AIDS (UNAIDS), 1990– neonatal mortality rate constrained so as not to exceed the under-five 2018 HIV and AIDS estimates, 2019. mortality rate. If a country had a negative ARR in 2000–2018 (i.e., an 30. Sawyer, Cheryl Chriss, ‘Child Mortality Estimation: Estimating sex increase in mortality rates in 2000–2018), the rate was held constant differences in childhood mortality since the 1970s’, PLoS Medicine , vol. 9, at the estimated 2018 value. If a country reached the current lowest no. 8, 2012. observed mortality level among countries with more than 10,000 live births during the projection period, the mortality rate was held constant 31. Alkema, Leontine, et al., ‘National, Regional, and Global Sex Ratios at that lowest observed level for the remainder of the projection period. of Infant, Child, and Under-5 Mortality and Identification of Countries Regional aggregates were calculated based on the projected country- With Outlying Ratios: A systematic assessment’, The Lancet Global Health , level estimates. Crisis mortality was removed from the estimates for vol. 2, no. 9, 1 September 2014, pp. e521–e530. the calculation of the ARR. Uncertainty intervals (90 per cent) in the projections are calculated by projecting each sample trajectory from the 32. Alexander, Monica, and Leontine Alkema, ‘Global Estimation of posterior distribution forward in the manner described above and taking Neonatal Mortality Using a Bayesian Hierarchical Splines Regression the 5th and 95th percentile for each year of the projection period. Model’, Demographic Research , vol. 38, 2018, pp. 335–372. 13. Lawn, Joy E., et al., ‘Every Newborn: Progress, priorities, and 33. Masquelier, Bruno, et al., ‘Global, Regional, and National Mortality potential beyond survival’, The Lancet , vol. 384, no. 9938, 12 July 2014, pp. Trends in Older Children and Young Adolescents (5–14 years) from 1990 189-205. to 2016: An analysis of empirical data’, The Lancet Global Health 6 , vol. 6, no. 10, 1 October 2018, pp. 1087–1099. 14. Sankar, M Jeeva, et al., ‘When Do Newborns Die? A systematic review of timing of overall and cause-specific neonatal deaths in developing 34. Centre for Research on the Epidemiology of Disasters, ‘EM-DAT: countries’, Journal of Perinatology, vol. 36 (Suppl 1: S1-S11), May 2016. The International Disaster Database’, Université Catholique de Louvain, Brussels, . 15. United Nations Children’s Fund, ‘Committing to Child Survival: A promised renewed’, progress report, September 2015. 35. World Health Organization, ‘WHO Methods and Data Sources for Country-level Causes of Death 2000–2017’, Global Health Estimates 16. World Health Organization, United Nations Children’s Fund, ‘Every Technical Paper WHO/HMM/IER/GHE/2018.4, WHO, Geneva, Newborn: An action plan to end preventable deaths’, 30 June 2014, 2018, , accessed 3 September 2019. plan>, accessed 3 September 2019. 36. Zeitlin, Jennifer, and Katherine Wildman, ‘Indicators for Monitoring 17. Economic and Social Council, ‘Statistical Commission Report on the and Evaluating Perinatal Health in Europe’, European Union Health Forty-eighth Session, 7–10 March 2017’, E/2017/24-E/CN.3/2017/35, Monitoring Programme, 2000, University of Oslo. United Nations, New York, 2017. 37. Graafmans, Wilco C., et. al., ‘Comparability of Published Perinatal 18. Alkema, Leontine, and Jin Rou New, ‘Global Estimation of Child Mortality Rates in Western Europe: The quantitative impact of Mortality Using a Bayesian B-spline Bias-reduction Method’, The Annals of differences in gestational age and birthweight criteria’, British Journal of Applied Statistics , vol. 8, no. 4, 2014, pp. 2122–2149. Obstetrics and Gynaecology, vol. 108, no. 12, 2001, pp. 1237–1245. 19. There were concerns about incompleteness of early infant mortality 38. Kramer, Michael S., et al., ‘Registration Artifacts in International data from civil registration. A European report on perinatal indicators, Comparisons of Infant Mortality’, Paediatric and Perinatal Epidemiology, for example, noted wide variation in how European countries define vol. 16, no. 1, 2014, pp. 16–22. infant mortality, due to differences in birth and death registration practices (that is, differences in the cut-off points for acceptable weight 39. Kingkade, W. Ward, and Cheryl Chriss Sawyer, ‘Infant Mortality or estimated gestation period to be registered as a birth and subsequent in Eastern Europe and the Former Soviet Union Before and After the death). 36, 37 This discrepancy can lead to underreporting of infant deaths Breakup’, Population Division, US Bureau of the Census, Washington, by some countries, particularly when compared with countries that use a DC, 2001, broader definition for live birth. 38, 39 accessed 3 September 2019. 35 STATISTICAL TABLE Country, regional and global estimates of mortality among children under age 5 and children aged 5–14 years Under-five mortality rate (U5MR) with 90 per cent uncertainty interval Number of under-five deaths with (deaths per 1,000 live births) 90 per cent uncertainty interval (thousands) a Annual rate of reduction 1990 2018 (ARR) (per cent) 1990 2018 1990–2018 Under- Under- Lower Upper Lower Upper Lower Upper five Lower Upper five Lower Upper Country U5MR bound bound U5MR bound bound ARR bound bound deaths bound bound deaths bound bound Afghanistan 179 164 195 62 50 75 3.8 3.0 4.6 111 102 120 74 60 90 Albania 41 36 46 9 8 9 5.5 5.0 6.0 3 3 4 0 0 0 Algeria 50 46 53 23 22 25 2.7 2.3 3.0 41 38 44 24 23 25 Andorra 11 7 19 3 2 5 4.7 1.8 7.7 0 0 0 0 0 0 Angola 223 198 252 77 36 144 3.8 1.5 6.5 126 112 142 94 44 175 Antigua and Barbuda 28 18 44 6 5 9 5.2 3.2 7.3 0 0 0 0 0 0 Argentina 29 28 29 10 10 11 3.8 3.6 4.0 21 20 21 8 7 8 Armenia 49 45 54 12 9 16 4.9 4.0 6.0 4 3 4 1 0 1 Australia 9 9 9 4 4 4 3.3 3.0 3.5 2 2 2 1 1 1 Austria 10 9 10 4 3 4 3.6 3.2 3.9 1 1 1 0 0 0 Azerbaijan 96 87 105 22 14 32 5.3 3.8 6.8 20 18 21 4 2 5 Bahamas 24 22 25 10 8 13 3.0 2.1 3.9 0 0 0 0 0 0 Bahrain 23 22 24 7 6 9 4.2 3.5 4.9 0 0 0 0 0 0 Bangladesh 144 140 148 30 27 33 5.6 5.2 6.0 512 498 528 89 80 98 Barbados 18 17 19 12 9 17 1.4 0.3 2.5 0 0 0 0 0 0 Belarus 15 15 16 3 3 4 5.3 5.1 5.6 2 2 2 0 0 0 Belgium 10 10 10 4 3 4 3.6 3.1 4.1 1 1 1 0 0 1 Belize 38 34 43 13 12 15 3.9 3.3 4.5 0 0 0 0 0 0 Benin 175 165 187 93 82 106 2.3 1.8 2.7 38 36 41 38 33 43 Bhutan 127 113 147 30 19 44 5.2 3.7 6.9 2 2 3 0 0 1 Bolivia (Plurinational State of) 121 115 128 27 21 34 5.4 4.5 6.3 29 27 30 7 5 8 Bosnia and Herzegovina 18 18 19 6 5 7 4.1 3.6 4.5 1 1 1 0 0 0 Botswana 51 44 59 36 16 73 1.2 -1.3 4.2 2 2 3 2 1 4 Brazil 63 59 68 14 13 17 5.3 4.7 5.8 233 217 250 42 37 48 Brunei Darussalam 13 13 14 12 10 13 0.6 0.0 1.1 0 0 0 0 0 0 Bulgaria 18 18 19 7 7 8 3.4 3.2 3.6 2 2 2 0 0 0 Burkina Faso 199 187 212 76 55 105 3.4 2.3 4.6 79 75 84 56 41 77 Burundi 174 158 192 58 40 85 3.9 2.5 5.3 46 41 50 25 17 36 Cabo Verde 61 59 63 19 16 25 4.1 3.2 4.9 1 1 1 0 0 0 Cambodia 116 107 125 28 15 50 5.1 3.0 7.2 44 41 48 10 6 18 Cameroon 137 128 147 76 60 96 2.1 1.3 3.0 69 65 75 66 52 84 Canada 8 8 8 5 5 5 1.8 1.6 2.0 3 3 3 2 2 2 Central African Republic 180 160 199 116 70 192 1.5 -0.3 3.4 21 18 23 19 11 32 Chad 212 197 229 119 92 150 2.1 1.2 3.0 60 56 65 75 58 94 Chile 19 19 20 7 6 9 3.5 2.8 4.2 6 5 6 2 1 2 China 54 50 59 9 8 10 6.5 6.0 7.1 1,377 1,273 1,501 146 128 167 Colombia 35 33 38 14 11 19 3.2 2.1 4.3 31 29 34 10 8 14 Comoros 125 111 140 67 34 142 2.2 -0.5 4.7 2 2 2 2 1 4 Congo 90 79 102 50 31 83 2.1 0.2 3.9 8 7 9 9 5 14 Cook Islands 24 22 27 8 5 13 4.0 2.2 5.8 0 0 0 0 0 0 Costa Rica 17 16 17 9 8 10 2.3 1.9 2.7 1 1 1 1 1 1 Côte d’Ivoire 155 145 166 81 66 99 2.3 1.6 3.1 76 71 82 70 57 86 Croatia 13 13 13 5 4 5 3.6 3.2 4.0 1 1 1 0 0 0 36 STATISTICAL TABLE (CONTINUED) Country, regional and global estimates of mortality among children under age 5 and children aged 5–14 years Probability of dying among Sex-specific under-five Infant Neonatal Number of children aged mortality rate mortality rate mortality rate Number of deaths among 5–14 years (deaths per 1,000 live births) (deaths per Number of (deaths per neonatal children aged (deaths per 1,000 live infant deaths 1,000 live deaths 1,000 children 5–14 years births) (thousands) a births) (thousands) a aged 5 years) (thousands)a 1990 2018 Country Male Female Male Female 1990 2018 1990 2018 1990 2018 1990 2018 1990 2018 1990 2018 Afghanistan 183 174 66 59 121 48 76 57 75 37 49 45 16 5 6 5 Albania 44 37 9 8 35 8 3 0 13 7 1 0 7 2 0 0 Algeria 54 45 25 22 42 20 35 21 23 15 19 15 9 4 6 3 Andorra 12 10 3 3 9 3 0 0 6 1 0 0 7 1 0 0 Angola 235 212 83 71 132 52 76 64 54 28 32 36 46 16 16 15 Antigua and Barbuda 31 25 7 6 24 5 0 0 15 3 0 0 5 1 0 0 Argentina 32 26 11 9 25 9 18 7 15 6 11 5 3 2 2 2 Armenia 54 44 14 11 42 11 3 0 23 6 2 0 3 2 0 0 Australia 10 8 4 3 8 3 2 1 5 2 1 1 2 1 0 0 Austria 11 8 4 3 8 3 1 0 5 2 0 0 2 1 0 0 Azerbaijan 101 90 24 19 76 19 16 3 33 11 7 2 5 3 1 0 Bahamas 25 22 11 9 20 8 0 0 13 5 0 0 4 2 0 0 Bahrain 24 22 7 7 20 6 0 0 15 3 0 0 4 2 0 0 Bangladesh 147 140 32 28 100 25 355 74 64 17 232 50 26 4 73 12 Barbados 20 16 13 11 16 11 0 0 12 8 0 0 3 2 0 0 Belarus 17 13 4 3 12 3 2 0 8 1 1 0 4 1 1 0 Belgium 11 9 4 3 8 3 1 0 5 2 1 0 2 1 0 0 Belize 42 35 14 12 31 11 0 0 19 9 0 0 5 3 0 0 Benin 183 168 99 87 106 61 24 25 46 31 11 13 45 22 7 7 Bhutan 132 122 32 27 89 25 2 0 43 16 1 0 20 7 0 0 Bolivia (Plurinational State of) 127 115 29 24 84 22 20 5 41 14 10 4 13 5 2 1 Bosnia and Herzegovina 20 16 6 5 16 5 1 0 11 4 1 0 3 1 0 0 Botswana 56 47 40 33 39 30 2 2 25 24 1 1 17 6 1 0 Brazil 69 57 16 13 53 13 194 37 25 8 94 24 5 2 16 7 Brunei Darussalam 15 12 12 11 10 10 0 0 6 5 0 0 4 2 0 0 Bulgaria 20 16 8 6 15 6 2 0 8 4 1 0 4 2 0 0 Burkina Faso 207 192 81 72 99 49 40 36 46 25 19 19 40 20 11 11 Burundi 182 166 63 54 105 41 28 18 40 22 11 9 62 23 10 7 Cabo Verde 65 56 21 18 47 17 1 0 20 12 0 0 6 2 0 0 Cambodia 124 108 31 25 85 24 32 9 40 14 15 5 35 5 9 2 Cameroon 144 129 81 71 85 51 44 45 40 27 21 24 35 32 12 22 Canada 9 7 5 5 7 4 3 2 4 3 2 1 2 1 1 0 Central African Republic 187 172 123 110 117 84 14 14 52 41 6 7 32 15 2 2 Chad 222 202 125 112 112 71 33 46 52 34 16 22 53 28 9 13 Chile 21 17 8 7 16 6 5 1 9 5 3 1 3 1 1 0 China 56 51 9 8 42 7 1,070 125 29 4 740 73 8 2 158 40 Colombia 39 31 16 13 29 12 26 9 18 8 16 6 5 2 4 2 Comoros 133 118 73 62 88 51 2 1 50 32 1 1 18 9 0 0 Congo 96 85 54 46 59 36 5 6 27 20 2 3 37 7 3 1 Cook Islands 27 21 9 7 20 7 0 0 13 4 0 0 5 2 0 0 Costa Rica 19 15 10 8 14 8 1 1 9 6 1 0 3 2 0 0 Côte d’Ivoire 166 142 89 73 105 59 53 52 49 34 26 30 31 25 10 17 Croatia 14 11 5 4 11 4 1 0 8 3 0 0 3 1 0 0 37 STATISTICAL TABLE (CONTINUED) Country, regional and global estimates of mortality among children under age 5 and children aged 5–14 years Under-five mortality rate (U5MR) with 90 per cent uncertainty interval Number of under-five deaths with (deaths per 1,000 live births) 90 per cent uncertainty interval (thousands) a Annual rate of reduction 1990 2018 (ARR) (per cent) 1990 2018 1990–2018 Under- Under- Lower Upper Lower Upper Lower Upper five Lower Upper five Lower Upper Country U5MR bound bound U5MR bound bound ARR bound bound deaths bound bound deaths bound bound Cuba 13 12 15 5 4 6 3.5 2.8 4.1 2 2 3 1 1 1 Cyprus 11 11 12 2 2 3 5.5 4.6 6.4 0 0 0 0 0 0 Czechia 12 12 12 3 3 4 4.6 4.2 5.0 2 2 2 0 0 0 Democratic People’s Republic of Korea 43 34 56 18 14 23 3.1 3.1 3.1 18 14 23 6 5 8 Democratic Republic of the Congo 186 168 206 88 59 129 2.7 1.3 4.1 283 257 312 296 197 432 Denmark 9 9 9 4 4 5 2.7 2.0 3.3 1 1 1 0 0 0 Djibouti 118 101 137 59 37 94 2.5 0.7 4.2 3 2 3 1 1 2 Dominica 16 15 18 36 28 46 -2.8 -3.8 -1.9 0 0 0 0 0 0 Dominican Republic 60 57 64 29 21 41 2.6 1.4 3.8 13 12 13 6 4 8 Ecuador 54 49 60 14 13 15 4.8 4.3 5.2 16 15 18 5 4 5 Egypt 86 82 90 21 16 29 5.0 3.9 6.1 159 152 166 55 40 75 El Salvador 60 55 65 14 9 21 5.3 3.7 6.7 10 9 11 2 1 2 Equatorial Guinea 179 158 201 85 51 134 2.7 1.0 4.5 3 3 3 4 2 6 Eritrea 153 141 166 42 26 67 4.6 2.9 6.3 14 13 15 4 3 7 Estonia 18 17 18 3 2 3 6.8 6.1 7.4 0 0 0 0 0 0 Eswatini 71 61 81 54 35 82 0.9 -0.6 2.5 2 2 3 2 1 2 Ethiopia 202 188 217 55 45 69 4.6 3.9 5.4 436 407 469 191 155 238 Fiji 29 25 35 26 24 28 0.5 -0.2 1.2 1 1 1 0 0 1 Finland 7 7 7 2 2 2 4.9 4.5 5.4 0 0 0 0 0 0 France 9 9 9 4 4 4 2.9 2.6 3.1 7 7 7 3 3 3 Gabon 93 80 108 45 29 69 2.6 0.9 4.3 3 3 4 3 2 5 Gambia 167 150 188 58 34 98 3.8 1.9 5.7 7 6 8 5 3 8 Georgia 48 43 53 10 8 12 5.7 4.9 6.3 4 4 5 1 0 1 Germany 9 8 9 4 3 4 3.0 2.6 3.4 7 7 7 3 3 3 Ghana 127 121 135 48 40 58 3.5 2.8 4.2 73 69 77 41 34 50 Greece 10 10 11 4 4 5 3.0 2.6 3.6 1 1 1 0 0 0 Grenada 22 21 24 15 13 19 1.4 0.6 2.1 0 0 0 0 0 0 Guatemala 80 75 85 26 21 34 4.0 3.1 4.9 28 27 30 11 9 14 Guinea 236 220 253 101 81 128 3.0 2.2 3.8 68 64 73 44 36 56 Guinea-Bissau 223 199 249 81 53 121 3.6 2.1 5.2 10 9 11 5 3 8 Guyana 60 55 67 30 19 48 2.5 0.8 4.1 1 1 1 0 0 1 Haiti 144 135 155 65 51 84 2.9 1.9 3.7 37 35 40 17 14 23 Honduras 58 54 63 18 12 26 4.3 2.9 5.6 11 10 12 4 3 5 Hungary 17 17 18 4 4 5 5.0 4.4 5.7 2 2 2 0 0 0 Iceland 6 6 7 2 2 3 4.2 3.1 5.3 0 0 0 0 0 0 India 126 122 131 37 33 40 4.4 4.0 4.8 3,417 3,304 3,534 882 788 974 Indonesia 84 80 88 25 22 29 4.3 3.8 4.9 394 376 413 121 104 141 Iran (Islamic Republic of) 56 52 61 14 9 23 4.9 3.2 6.5 103 95 112 22 14 34 Iraq 54 49 59 27 21 34 2.5 1.6 3.4 35 32 38 29 23 37 Ireland 9 9 10 4 3 5 3.3 2.5 4.0 0 0 1 0 0 0 Israel 12 11 12 4 4 4 4.1 3.8 4.3 1 1 1 1 1 1 Italy 10 10 10 3 3 3 4.1 3.8 4.5 5 5 6 1 1 2 Jamaica 30 26 36 14 9 25 2.7 0.7 4.6 2 2 2 1 0 1 38 STATISTICAL TABLE (CONTINUED) Country, regional and global estimates of mortality among children under age 5 and children aged 5–14 years Probability of dying among Sex-specific under-five Infant Neonatal Number of children aged mortality rate mortality rate mortality rate Number of deaths among 5–14 years (deaths per 1,000 live births) (deaths per Number of (deaths per neonatal children aged (deaths per 1,000 live infant deaths 1,000 live deaths 1,000 children 5–14 years births) (thousands) a births) (thousands) a aged 5 years) (thousands)a 1990 2018 Country Male Female Male Female 1990 2018 1990 2018 1990 2018 1990 2018 1990 2018 1990 2018 Cuba 15 12 5 4 11 4 2 0 7 2 1 0 4 2 1 0 Cyprus 12 10 3 2 10 2 0 0 6 1 0 0 2 1 0 0 Czechia 14 11 4 3 10 3 1 0 7 2 1 0 2 1 0 0 Democratic People’s Republic of Korea 47 39 20 16 33 14 14 5 22 10 9 3 8 4 3 1 Democratic Republic of the Congo 194 177 95 81 119 68 186 232 42 28 67 98 41 29 40 70 Denmark 10 8 5 4 7 4 0 0 4 3 0 0 2 0 0 0 Djibouti 126 110 64 54 92 50 2 1 50 32 1 1 26 13 0 0 Dominica 17 15 38 33 13 33 0 0 10 28 0 0 3 3 0 0 Dominican Republic 64 56 32 26 46 24 10 5 24 19 5 4 8 3 1 1 Ecuador 59 49 16 13 42 12 13 4 23 7 7 2 8 3 2 1 Egypt 86 86 22 20 63 18 116 47 33 11 62 29 11 4 16 9 El Salvador 64 55 15 12 46 12 8 1 23 7 4 1 7 4 1 0 Equatorial Guinea 188 170 91 79 121 63 2 3 48 30 1 1 38 18 0 1 Eritrea 166 139 47 36 94 31 8 3 35 18 3 2 45 9 3 1 Estonia 20 15 3 2 14 2 0 0 10 1 0 0 5 1 0 0 Eswatini 77 65 59 49 54 43 2 1 21 17 1 1 11 13 0 0 Ethiopia 215 188 61 49 120 39 265 137 59 28 136 99 78 12 111 34 Fiji 32 27 28 23 24 22 1 0 12 11 0 0 10 5 0 0 Finland 7 6 2 2 6 1 0 0 4 1 0 0 2 1 0 0 France 10 8 4 4 7 3 6 2 4 3 3 2 2 1 1 1 Gabon 99 86 49 40 60 33 2 2 31 21 1 1 19 14 0 1 Gambia 176 158 63 54 82 39 4 3 49 26 2 2 36 13 1 1 Georgia 53 43 11 9 41 9 4 0 25 6 2 0 7 2 1 0 Germany 10 7 4 3 7 3 6 2 3 2 3 2 2 1 2 1 Ghana 135 119 52 43 80 35 46 30 42 24 25 21 27 12 11 8 Greece 11 10 5 4 9 4 1 0 6 3 1 0 2 1 0 0 Grenada 24 20 17 14 18 14 0 0 12 10 0 0 3 5 0 0 Guatemala 85 74 29 23 59 22 21 9 28 12 10 5 12 4 3 1 Guinea 243 228 105 96 139 65 41 29 62 31 19 14 49 21 9 8 Guinea-Bissau 234 211 88 75 132 54 6 4 64 37 3 2 40 16 1 1 Guyana 67 53 34 26 47 25 1 0 31 18 1 0 6 5 0 0 Haiti 153 136 70 59 100 49 26 13 39 26 10 7 31 12 6 3 Honduras 63 53 19 16 45 15 8 3 22 10 4 2 9 5 1 1 Hungary 19 15 5 4 15 4 2 0 11 2 1 0 3 1 0 0 Iceland 7 6 2 2 5 2 0 0 3 1 0 0 2 1 0 0 India 122 131 36 37 89 30 2,399 721 57 23 1,578 549 21 6 447 143 Indonesia 91 78 28 22 62 21 288 102 31 13 144 62 15 6 66 28 Iran (Islamic Republic of) 56 56 15 14 44 12 79 19 26 9 47 14 8 3 14 3 Iraq 58 50 29 24 42 22 27 25 26 15 17 17 9 7 5 7 Ireland 10 8 4 3 8 3 0 0 5 2 0 0 2 1 0 0 Israel 12 11 4 3 10 3 1 1 6 2 1 0 2 1 0 0 Italy 11 9 3 3 8 3 5 1 6 2 4 1 2 1 1 0 Jamaica 34 27 16 13 25 12 2 1 20 10 1 0 5 3 0 0 39 STATISTICAL TABLE (CONTINUED) Country, regional and global estimates of mortality among children under age 5 and children aged 5–14 years Under-five mortality rate (U5MR) with 90 per cent uncertainty interval Number of under-five deaths with (deaths per 1,000 live births) 90 per cent uncertainty interval (thousands) a Annual rate of reduction 1990 2018 (ARR) (per cent) 1990 2018 1990–2018 Under- Under- Lower Upper Lower Upper Lower Upper five Lower Upper five Lower Upper Country U5MR bound bound U5MR bound bound ARR bound bound deaths bound bound deaths bound bound Japan 6 6 6 2 2 3 3.3 3.1 3.5 8 8 9 2 2 3 Jordan 36 34 39 16 13 21 2.9 1.9 3.8 4 4 5 3 3 5 Kazakhstan 52 48 57 10 10 10 5.9 5.6 6.3 20 18 22 4 4 4 Kenya 107 100 114 41 31 55 3.4 2.4 4.4 105 99 112 60 46 80 Kiribati 95 82 111 53 32 86 2.1 0.3 4.0 0 0 0 0 0 0 Kuwait 18 17 18 8 7 9 2.9 2.5 3.2 1 1 1 0 0 0 Kyrgyzstan 65 57 73 19 18 20 4.4 3.9 4.9 9 8 10 3 3 3 Lao People’s Democratic Republic 153 141 167 47 36 61 4.2 3.3 5.2 27 25 29 8 6 10 Latvia 17 17 18 4 3 5 5.3 4.7 5.9 1 1 1 0 0 0 Lebanon 32 29 36 7 4 14 5.2 3.0 7.8 3 2 3 1 0 2 Lesotho 90 82 99 81 57 113 0.4 -0.8 1.6 5 5 6 5 3 6 Liberia 262 241 285 71 50 102 4.7 3.4 5.9 25 23 27 11 8 16 Libya 42 36 49 12 8 18 4.4 2.8 6.1 5 5 6 2 1 2 Lithuania 15 15 16 4 4 5 4.7 4.2 5.2 1 1 1 0 0 0 Luxembourg 9 8 9 2 2 3 4.6 3.6 5.6 0 0 0 0 0 0 Madagascar 159 148 171 54 40 71 3.9 2.9 5.0 78 73 84 45 34 59 Malawi 239 225 253 50 35 70 5.6 4.4 6.9 98 93 104 30 21 43 Malaysia 17 16 17 8 7 8 2.7 2.4 3.0 8 8 8 4 4 4 Maldives 86 78 94 9 7 11 8.2 7.3 9.1 1 1 1 0 0 0 Mali 230 216 244 98 81 117 3.1 2.4 3.7 91 86 97 75 63 90 Malta 11 11 12 7 6 9 1.7 1.0 2.4 0 0 0 0 0 0 Marshall Islands 49 42 57 33 22 50 1.4 -0.2 3.0 0 0 0 0 0 0 Mauritania 117 105 130 76 40 143 1.6 -0.8 3.9 9 8 10 11 6 21 Mauritius 23 22 24 16 14 17 1.4 1.0 1.8 1 0 1 0 0 0 Mexico 45 42 49 13 12 13 4.5 4.2 4.8 108 100 117 28 27 30 Micronesia (Federated States of) 55 45 69 31 13 75 2.1 -0.9 5.0 0 0 0 0 0 0 Monaco 8 7 9 3 2 5 3.2 1.9 4.4 0 0 0 0 0 0 Mongolia 108 99 117 16 10 25 6.7 5.2 8.4 8 7 8 1 1 2 Montenegro 17 16 17 3 2 3 6.7 5.9 7.4 0 0 0 0 0 0 Morocco 79 74 85 22 17 29 4.5 3.5 5.4 57 54 62 15 12 20 Mozambique 241 222 262 73 53 104 4.3 3.0 5.4 140 129 151 79 57 112 Myanmar 115 106 126 46 33 62 3.3 2.1 4.5 131 120 143 43 31 59 Namibia 74 67 81 40 25 65 2.2 0.4 3.9 4 4 4 3 2 4 Nauru 60 36 101 32 18 55 2.2 -0.7 5.3 0 0 0 0 0 0 Nepal 140 132 149 32 25 41 5.2 4.4 6.1 99 93 105 18 14 23 Netherlands 8 8 9 4 4 4 2.7 2.5 2.9 2 2 2 1 1 1 New Zealand 11 11 11 6 5 7 2.4 1.8 3.0 1 1 1 0 0 0 Nicaragua 66 62 72 18 17 19 4.6 4.3 4.9 10 9 11 2 2 3 Niger 329 307 351 84 56 125 4.9 3.4 6.4 137 128 147 83 55 123 Nigeria 211 198 225 120 97 151 2.0 1.2 2.8 853 800 910 866 701 1,094 Niue 13 8 22 24 10 56 -2.1 -5.7 1.7 0 0 0 0 0 0 North Macedonia 36 35 38 10 8 12 4.7 4.0 5.5 1 1 1 0 0 0 Norway 9 8 9 3 2 3 4.4 3.9 4.8 0 0 1 0 0 0 40 STATISTICAL TABLE (CONTINUED) Country, regional and global estimates of mortality among children under age 5 and children aged 5–14 years Probability of dying among Sex-specific under-five Infant Neonatal Number of children aged mortality rate mortality rate mortality rate Number of deaths among 5–14 years (deaths per 1,000 live births) (deaths per Number of (deaths per neonatal children aged (deaths per 1,000 live infant deaths 1,000 live deaths 1,000 children 5–14 years births) (thousands) a births) (thousands) a aged 5 years) (thousands)a 1990 2018 Country Male Female Male Female 1990 2018 1990 2018 1990 2018 1990 2018 1990 2018 1990 2018 Japan 7 6 3 2 5 2 6 2 3 1 3 1 2 1 3 1 Jordan 38 34 18 15 30 14 4 3 20 9 3 2 5 3 1 1 Kazakhstan 58 46 11 9 44 9 17 3 22 6 8 2 6 3 2 1 Kenya 112 101 45 37 68 31 67 45 28 20 28 29 18 10 13 14 Kiribati 102 89 57 48 69 41 0 0 36 23 0 0 16 9 0 0 Kuwait 19 16 9 7 15 7 1 0 10 4 0 0 5 2 0 0 Kyrgyzstan 70 59 21 17 54 17 7 3 24 13 3 2 6 3 1 0 Lao People’s Democratic Republic 162 144 52 42 105 38 19 6 47 23 9 4 44 9 5 1 Latvia 19 15 4 4 13 3 0 0 8 2 0 0 6 1 0 0 Lebanon 34 31 8 7 27 6 2 1 20 4 2 1 8 2 1 0 Lesotho 97 83 88 74 72 66 4 4 39 35 2 2 17 9 1 0 Liberia 275 248 76 65 175 53 16 8 59 24 5 4 33 17 2 2 Libya 45 38 13 11 35 10 5 1 21 6 3 1 8 6 1 1 Lithuania 17 13 4 4 12 3 1 0 8 2 0 0 4 1 0 0 Luxembourg 10 8 3 2 7 2 0 0 4 1 0 0 2 0 0 0 Madagascar 167 152 58 49 97 38 49 32 39 21 20 18 41 12 14 8 Malawi 250 227 54 45 139 35 58 22 50 22 21 14 40 14 11 7 Malaysia 18 15 8 7 14 7 7 4 8 4 4 2 5 3 2 1 Maldives 91 80 9 8 63 7 1 0 39 5 0 0 12 2 0 0 Mali 238 221 103 92 120 62 48 48 67 33 28 26 44 26 11 15 Malta 12 10 8 6 10 6 0 0 8 5 0 0 2 1 0 0 Marshall Islands 53 44 37 29 39 27 0 0 20 15 0 0 9 6 0 0 Mauritania 124 109 81 70 71 52 6 8 46 33 4 5 21 8 1 1 Mauritius 26 20 17 14 20 14 0 0 15 9 0 0 4 2 0 0 Mexico 48 41 14 11 36 11 86 24 22 8 53 17 5 2 11 6 Micronesia (Federated States of) 60 51 34 27 43 26 0 0 26 16 0 0 10 6 0 0 Monaco 9 7 4 3 6 3 0 0 4 2 0 0 2 1 0 0 Mongolia 122 93 19 13 77 14 5 1 30 9 2 1 10 4 1 0 Montenegro 18 15 3 2 15 2 0 0 11 2 0 0 2 1 0 0 Morocco 84 74 25 20 62 19 45 13 36 14 26 9 10 3 7 2 Mozambique 250 232 78 68 161 54 93 59 60 28 36 31 60 17 24 14 Myanmar 122 107 51 42 82 37 92 35 48 23 54 22 31 5 33 5 Namibia 79 68 43 36 50 29 3 2 28 16 1 1 16 12 1 1 Nauru 64 55 35 29 46 26 0 0 29 20 0 0 11 6 0 0 Nepal 141 139 34 30 97 27 69 15 58 20 43 11 29 6 15 3 Netherlands 9 7 4 3 7 3 1 1 5 2 1 0 2 1 0 0 New Zealand 12 10 6 5 9 5 1 0 4 3 0 0 3 1 0 0 Nicaragua 72 61 20 16 51 16 8 2 23 9 3 1 8 4 1 0 Niger 331 326 87 80 133 48 57 49 54 25 24 26 68 37 17 26 Nigeria 221 200 127 113 125 76 512 552 50 36 211 267 41 20 111 110 Niue 15 12 26 21 12 20 0 0 7 12 0 0 4 5 0 0 North Macedonia 39 34 11 9 33 9 1 0 17 7 1 0 3 1 0 0 Norway 10 8 3 2 7 2 0 0 4 1 0 0 2 1 0 0 41 STATISTICAL TABLE (CONTINUED) Country, regional and global estimates of mortality among children under age 5 and children aged 5–14 years Under-five mortality rate (U5MR) with 90 per cent uncertainty interval Number of under-five deaths with (deaths per 1,000 live births) 90 per cent uncertainty interval (thousands) a Annual rate of reduction 1990 2018 (ARR) (per cent) 1990 2018 1990–2018 Under- Under- Lower Upper Lower Upper Lower Upper five Lower Upper five Lower Upper Country U5MR bound bound U5MR bound bound ARR bound bound deaths bound bound deaths bound bound Oman 39 34 45 11 11 12 4.4 3.8 4.9 3 2 3 1 1 1 Pakistan 139 134 144 69 56 85 2.5 1.8 3.2 593 572 615 409 332 498 Palau 35 30 42 18 10 34 2.4 0.0 4.8 0 0 0 0 0 0 Panama 31 27 34 15 9 28 2.5 0.3 4.6 2 2 2 1 1 2 Papua New Guinea 87 79 95 48 38 60 2.1 1.3 3.0 14 12 15 11 9 14 Paraguay 45 41 51 20 11 38 2.9 0.6 5.1 6 6 7 3 2 5 Peru 81 77 85 14 11 19 6.2 5.2 7.0 54 51 57 8 6 11 Philippines 57 53 61 28 22 36 2.5 1.6 3.3 113 106 121 63 49 80 Poland 17 17 18 4 4 5 4.9 4.7 5.0 10 10 10 2 2 2 Portugal 15 14 15 4 4 4 4.9 4.6 5.1 2 2 2 0 0 0 Qatar 21 20 22 7 6 8 4.0 3.5 4.4 0 0 0 0 0 0 Republic of Korea 15 15 16 3 3 4 5.6 5.3 6.0 10 10 11 1 1 1 Republic of Moldova 33 29 39 16 12 21 2.7 1.4 3.8 3 2 3 1 0 1 Romania 31 30 32 7 6 9 5.2 4.5 5.9 10 10 11 1 1 2 Russian Federation 22 21 22 7 6 8 3.9 3.5 4.4 45 45 46 13 12 15 Rwanda 154 144 164 35 21 59 5.3 3.4 7.1 49 46 52 13 8 23 Saint Kitts and Nevis 31 28 34 12 9 16 3.4 2.2 4.5 0 0 0 0 0 0 Saint Lucia 22 21 24 17 13 22 1.1 0.0 2.1 0 0 0 0 0 0 Saint Vincent and the Grenadines 24 22 25 16 13 20 1.3 0.5 2.2 0 0 0 0 0 0 Samoa 30 26 34 16 11 22 2.3 1.0 3.6 0 0 0 0 0 0 San Marino 13 10 17 2 1 4 6.8 4.1 9.4 0 0 0 0 0 0 Sao Tome and Principe 108 96 122 31 20 49 4.4 2.8 6.2 0 0 1 0 0 0 Saudi Arabia 45 37 54 7 6 9 6.6 5.4 7.7 25 21 30 4 3 5 Senegal 139 132 146 44 34 57 4.1 3.1 5.1 43 41 45 23 18 31 Serbia 28 27 29 6 5 6 5.8 5.3 6.2 4 4 4 0 0 1 Seychelles 17 15 18 14 11 18 0.5 -0.4 1.4 0 0 0 0 0 0 Sierra Leone 263 242 284 105 85 128 3.3 2.5 4.1 50 46 54 26 21 32 Singapore 8 7 8 3 2 3 3.6 3.0 4.2 0 0 0 0 0 0 Slovakia 15 15 15 6 5 6 3.5 3.3 3.7 1 1 1 0 0 0 Slovenia 10 10 11 2 2 3 5.6 5.1 6.1 0 0 0 0 0 0 Solomon Islands 39 34 44 20 14 29 2.3 0.9 3.8 0 0 1 0 0 1 Somalia 179 150 219 122 65 233 1.4 -0.8 3.5 59 49 72 73 39 140 South Africa 59 52 66 34 30 38 2.0 1.4 2.6 66 59 74 40 35 45 South Sudan 254 212 297 99 44 186 3.4 0.9 6.4 63 53 73 38 17 71 Spain 9 9 9 3 3 3 3.9 3.7 4.2 4 4 4 1 1 1 Sri Lanka 22 22 22 7 6 9 3.9 3.3 4.4 8 8 8 3 2 3 State of Palestine 44 41 48 20 15 28 2.8 1.6 4.0 4 4 4 3 2 4 Sudan 132 122 142 60 46 79 2.8 1.8 3.8 106 99 115 80 61 104 Suriname 48 40 57 19 9 40 3.3 0.6 5.9 1 0 1 0 0 0 Sweden 7 7 7 3 3 3 3.4 3.1 3.6 1 1 1 0 0 0 Switzerland 8 8 9 4 4 5 2.5 2.0 2.9 1 1 1 0 0 0 Syrian Arab Republic 37 34 41 17 13 25 2.9 1.3 4.0 17 15 18 7 5 11 Tajikistan 102 93 112 35 24 51 3.8 2.4 5.2 21 19 23 10 7 14 42 STATISTICAL TABLE (CONTINUED) Country, regional and global estimates of mortality among children under age 5 and children aged 5–14 years Probability of dying among Sex-specific under-five Infant Neonatal Number of children aged mortality rate mortality rate mortality rate Number of deaths among 5–14 years (deaths per 1,000 live births) (deaths per Number of (deaths per neonatal children aged (deaths per 1,000 live infant deaths 1,000 live deaths 1,000 children 5–14 years births) (thousands) a births) (thousands) a aged 5 years) (thousands)a 1990 2018 Country Male Female Male Female 1990 2018 1990 2018 1990 2018 1990 2018 1990 2018 1990 2018 Oman 42 35 12 10 32 10 2 1 17 5 1 0 6 2 0 0 Pakistan 141 136 74 65 106 57 458 338 65 42 287 251 14 10 39 46 Palau 39 32 20 16 30 17 0 0 19 9 0 0 7 4 0 0 Panama 34 28 17 14 26 13 2 1 17 8 1 1 8 3 0 0 Papua New Guinea 93 81 52 44 64 38 10 9 31 22 5 5 15 9 2 2 Paraguay 49 41 22 18 36 17 5 2 22 11 3 2 7 3 1 0 Peru 85 76 16 13 57 11 38 6 28 7 19 4 11 3 6 2 Philippines 62 51 31 25 40 22 81 49 19 14 39 30 14 5 23 12 Poland 19 15 5 4 15 4 9 1 11 3 6 1 3 1 2 0 Portugal 16 13 4 3 12 3 1 0 7 2 1 0 4 1 1 0 Qatar 23 19 7 6 18 6 0 0 11 4 0 0 4 1 0 0 Republic of Korea 17 14 3 3 13 3 9 1 7 1 5 1 5 1 4 0 Republic of Moldova 37 30 18 14 28 14 2 1 19 12 2 0 5 2 0 0 Romania 34 28 8 7 24 6 8 1 15 3 5 1 5 2 2 0 Russian Federation 25 18 8 6 18 6 38 11 11 3 22 6 5 2 12 4 Rwanda 162 145 38 32 94 27 30 10 40 16 13 6 72 10 17 3 Saint Kitts and Nevis 34 28 13 11 25 10 0 0 19 8 0 0 5 2 0 0 Saint Lucia 25 20 18 15 19 15 0 0 12 12 0 0 4 2 0 0 Saint Vincent and the Grenadines 26 22 18 15 20 15 0 0 13 10 0 0 4 5 0 0 Samoa 33 27 17 14 25 14 0 0 16 8 0 0 6 4 0 0 San Marino 14 12 2 2 12 2 0 0 7 1 0 0 2 1 0 0 Sao Tome and Principe 114 102 34 28 69 24 0 0 26 14 0 0 20 8 0 0 Saudi Arabia 47 42 7 7 36 6 20 4 22 4 13 2 7 2 3 1 Senegal 146 132 48 39 71 32 22 17 40 21 13 11 37 13 8 6 Serbia 30 26 6 5 24 5 3 0 17 3 2 0 3 1 0 0 Seychelles 18 15 16 13 14 12 0 0 11 9 0 0 4 3 0 0 Sierra Leone 274 251 111 99 156 78 30 20 53 33 10 8 53 21 7 4 Singapore 8 7 3 3 6 2 0 0 4 1 0 0 2 1 0 0 Slovakia 16 13 6 5 13 5 1 0 9 3 1 0 3 1 0 0 Slovenia 11 9 2 2 9 2 0 0 6 1 0 0 2 1 0 0 Solomon Islands 42 35 22 18 31 17 0 0 15 8 0 0 8 4 0 0 Somalia 187 171 127 115 108 77 36 47 45 38 15 24 38 24 7 11 South Africa 64 54 37 31 46 28 51 34 20 11 23 13 8 6 8 6 South Sudan 261 246 103 93 150 64 37 24 65 40 16 15 52 20 8 6 Spain 10 8 3 3 7 3 3 1 5 2 2 1 2 1 1 0 Sri Lanka 24 20 8 7 19 6 7 2 13 4 5 2 6 2 2 1 State of Palestine 47 42 22 18 36 17 3 2 22 11 2 2 6 3 0 0 Sudan 139 124 65 55 82 42 68 56 43 29 37 38 29 8 17 9 Suriname 52 43 21 17 41 17 0 0 23 10 0 0 7 3 0 0 Sweden 8 6 3 2 6 2 1 0 4 2 0 0 1 1 0 0 Switzerland 9 7 4 4 7 4 1 0 4 3 0 0 2 1 0 0 Syrian Arab Republic 40 34 17 15 30 14 14 6 17 9 8 4 9 12 3 4 Tajikistan 110 94 39 31 81 30 17 8 31 15 7 4 12 5 2 1 43 STATISTICAL TABLE (CONTINUED) Country, regional and global estimates of mortality among children under age 5 and children aged 5–14 years Under-five mortality rate (U5MR) with 90 per cent uncertainty interval Number of under-five deaths with (deaths per 1,000 live births) 90 per cent uncertainty interval (thousands) a Annual rate of reduction 1990 2018 (ARR) (per cent) 1990 2018 1990–2018 Under- Under- Lower Upper Lower Upper Lower Upper five Lower Upper five Lower Upper Country U5MR bound bound U5MR bound bound ARR bound bound deaths bound bound deaths bound bound Thailand 37 35 39 9 8 12 5.0 4.1 5.6 40 38 43 7 6 8 Timor-Leste 174 157 193 46 28 74 4.8 3.0 6.5 5 5 6 2 1 3 Togo 145 135 157 70 53 92 2.6 1.6 3.7 22 20 24 18 13 24 Tonga 22 19 27 16 9 26 1.3 -0.7 3.2 0 0 0 0 0 0 Trinidad and Tobago 30 25 36 18 8 43 1.8 -1.3 4.6 1 1 1 0 0 1 Tunisia 55 49 63 17 16 18 4.2 3.7 4.7 12 11 14 3 3 4 Turkey 74 69 79 11 9 12 6.9 6.4 7.4 103 97 111 14 12 16 Turkmenistan 85 73 98 46 19 101 2.2 -0.7 5.4 11 9 13 6 3 14 Tuvalu 53 44 64 24 14 44 2.8 0.6 5.0 0 0 0 0 0 0 Uganda 185 175 196 46 37 59 4.9 4.1 5.8 150 142 159 74 58 94 Ukraine 19 17 22 9 8 10 2.9 2.4 3.4 13 12 15 4 4 4 United Arab Emirates 17 14 20 8 7 9 2.8 2.1 3.5 1 1 1 1 1 1 United Kingdom 9 9 10 4 4 5 2.8 2.5 3.1 7 7 7 3 3 4 United Republic of Tanzania 166 157 176 53 41 69 4.1 3.1 5.0 176 167 187 107 83 139 United States 11 11 11 7 6 7 1.9 1.7 2.2 44 43 45 25 24 27 Uruguay 23 23 23 8 7 8 4.0 3.7 4.2 1 1 1 0 0 0 Uzbekistan 72 64 81 21 17 27 4.3 3.6 5.1 51 45 57 15 12 19 Vanuatu 36 30 43 26 17 42 1.1 -0.7 2.9 0 0 0 0 0 0 Venezuela (Bolivarian Republic of) 30 29 30 25 21 29 0.7 0.1 1.2 16 16 17 13 11 15 Viet Nam 51 47 56 21 17 25 3.2 2.5 3.9 99 91 107 33 28 40 Yemen 126 118 134 55 35 84 3.0 1.5 4.5 75 70 80 47 30 72 Zambia 186 174 198 58 44 76 4.2 3.2 5.1 65 61 69 36 27 47 Zimbabwe 80 74 88 46 32 65 2.0 0.7 3.3 30 27 32 21 14 29 Estimates of mortality among children under age 5 and children aged 5–14 years by Sustainable Development Goal regionb Sub-Saharan Africa 182 178 186 78 73 88 3.0 2.6 3.3 3,751 3,679 3,834 2,789 2,598 3,128 Northern Africa and Western Asia 74 73 76 26 23 30 3.8 3.3 4.2 681 666 698 296 267 340 Northern Africa 84 81 87 30 26 36 3.6 3.0 4.2 381 370 394 179 155 212 Western Asia 65 63 68 21 18 26 4.0 3.3 4.6 300 290 311 117 100 144 Central Asia and Southern Asia 124 121 127 40 37 44 4.0 3.7 4.3 4,958 4,840 5,079 1,534 1,413 1,666 Central Asia 72 68 77 23 19 29 4.1 3.3 4.7 112 105 119 38 32 48 Southern Asia 126 123 129 41 38 45 4.0 3.7 4.3 4,846 4,729 4,968 1,497 1,374 1,627 Eastern and South-Eastern Asia 57 54 60 15 14 16 4.8 4.5 5.1 2,284 2,176 2,411 448 417 487 Eastern Asia 51 47 55 8 7 10 6.4 5.9 7.0 1,422 1,318 1,545 157 139 179 South-Eastern Asia 72 70 74 25 23 28 3.7 3.3 4.1 862 838 888 291 266 324 Latin America and the Caribbean 55 53 56 16 16 18 4.3 4.0 4.5 641 622 661 172 165 184 Oceania 36 34 39 21 18 25 1.9 1.2 2.6 19 17 20 14 12 17 Australia and New Zealand 10 9 10 4 4 4 3.1 2.9 3.3 3 3 3 2 1 2 Oceania (exc. Australia and New Zealand) 74 68 80 43 35 52 2.0 1.2 2.7 16 15 17 13 10 15 Europe and Northern America 14 14 14 6 5 6 3.3 3.2 3.4 191 189 193 67 65 70 Europe 15 15 16 5 5 5 4.0 3.8 4.1 144 142 146 40 38 42 Northern America 11 11 11 6 6 7 1.9 1.7 2.1 47 46 48 27 26 29 Landlocked developing countries 167 164 171 58 54 64 3.8 3.4 4.1 1,757 1,719 1,799 897 839 994 Least developed countries 175 173 178 64 60 72 3.6 3.2 3.8 3,605 3,555 3,672 1,992 1,874 2,223 Small island developing States 78 76 81 40 36 46 2.4 1.9 2.8 93 90 97 48 43 56 World 93 92 95 39 37 42 3.1 2.9 3.3 12,524 12,352 12,724 5,322 5,100 5,709 44 STATISTICAL TABLE (CONTINUED) Country, regional and global estimates of mortality among children under age 5 and children aged 5–14 years Probability of dying among Sex-specific under-five Infant Neonatal Number of children aged mortality rate mortality rate mortality rate Number of deaths among 5–14 years (deaths per 1,000 live births) (deaths per Number of (deaths per neonatal children aged (deaths per 1,000 live infant deaths 1,000 live deaths 1,000 children 5–14 years births) (thousands) a births) (thousands) a aged 5 years) (thousands)a 1990 2018 Country Male Female Male Female 1990 2018 1990 2018 1990 2018 1990 2018 1990 2018 1990 2018 Thailand 41 33 10 8 30 8 33 6 20 5 22 4 9 5 11 4 Timor-Leste 181 167 50 42 131 39 4 1 55 20 2 1 27 8 0 0 Togo 154 136 75 64 90 47 14 12 43 25 7 6 37 21 4 4 Tonga 20 24 14 17 19 13 0 0 10 7 0 0 5 3 0 0 Trinidad and Tobago 33 28 20 17 27 16 1 0 20 12 0 0 4 2 0 0 Tunisia 59 52 18 15 43 15 9 3 29 11 6 2 7 3 2 1 Turkey 76 71 11 10 55 9 77 12 33 5 46 7 9 2 12 3 Turkmenistan 94 75 52 40 68 39 9 5 28 21 4 3 7 4 1 0 Tuvalu 57 50 27 22 42 21 0 0 28 16 0 0 10 5 0 0 Uganda 197 172 51 42 109 34 91 54 39 20 34 32 32 15 16 19 Ukraine 21 17 10 8 17 7 11 3 12 5 8 2 4 2 3 1 United Arab Emirates 19 15 8 7 14 6 1 1 8 4 0 0 5 2 0 0 United Kingdom 10 8 5 4 8 4 6 3 4 3 3 2 2 1 1 1 United Republic of Tanzania 172 160 57 49 101 38 109 77 40 21 44 44 30 13 22 20 United States 12 10 7 6 9 6 37 22 6 4 23 14 2 1 9 6 Uruguay 25 20 8 7 20 6 1 0 12 5 1 0 3 2 0 0 Uzbekistan 81 64 24 18 60 19 42 13 31 12 22 8 6 3 3 2 Vanuatu 38 33 28 24 29 22 0 0 17 12 0 0 7 5 0 0 Venezuela (Bolivarian Republic of) 32 27 26 23 25 21 14 11 13 15 7 8 4 3 2 2 Viet Nam 59 43 24 17 37 16 71 26 24 11 46 17 12 3 20 4 Yemen 131 120 59 51 88 43 54 37 43 27 27 23 20 8 7 6 Zambia 194 177 63 53 111 40 39 25 37 23 13 15 30 12 7 6 Zimbabwe 87 74 51 42 52 34 19 15 24 21 9 9 14 13 4 5 Estimates of mortality among children under age 5 and children aged 5–14 years by Sustainable Development Goal regionb (continued) Sub-Saharan Africa 191 172 84 72 108 53 2,276 1,917 46 28 985 1,016 40 18 575 510 Northern Africa and Western Asia 78 71 28 24 55 21 507 237 31 14 284 157 11 5 83 46 Northern Africa 87 81 32 28 61 24 278 141 33 16 153 95 13 5 48 23 Western Asia 68 62 23 20 49 17 229 96 28 11 131 62 9 4 35 23 Central Asia and Southern Asia 122 126 41 39 88 33 3,538 1,260 56 25 2,285 942 19 6 605 219 Central Asia 79 64 26 20 59 20 92 33 28 12 44 19 7 3 8 5 Southern Asia 124 128 42 40 90 34 3,446 1,226 57 25 2,241 922 20 6 597 214 Eastern and South-Eastern Asia 60 54 16 14 43 12 1,730 371 28 7 1,095 224 10 3 337 100 Eastern Asia 53 48 9 8 40 7 1,103 133 28 4 760 78 7 2 169 43 South-Eastern Asia 78 66 28 22 52 21 627 238 28 13 335 146 15 5 169 57 Latin America and the Caribbean 59 50 18 15 43 14 509 147 23 9 267 95 6 3 63 30 Oceania 39 33 23 19 27 17 14 11 14 10 7 7 6 4 3 2 Australia and New Zealand 11 8 4 4 8 3 2 1 5 2 1 1 2 1 1 0 Oceania (exc. Australia and New Zealand) 79 69 46 39 55 34 12 10 27 20 6 6 13 8 2 2 Europe and Northern America 16 12 6 5 12 5 159 57 7 3 98 36 3 1 42 16 Europe 17 13 6 5 13 4 120 34 8 3 74 21 3 1 33 10 Northern America 12 10 7 6 9 5 40 24 6 3 24 15 2 1 9 6 Landlocked developing countries 175 159 62 53 101 40 1,078 630 47 25 521 392 38 13 277 173 Least developed countries 183 168 69 59 108 46 2,264 1,432 52 26 1,113 821 39 14 571 371 Small island developing States 83 73 43 36 56 31 67 38 27 19 32 23 13 7 13 8 World 96 91 41 36 65 29 8,733 4,000 37 18 5,022 2,476 15 7 1,708 923 45 STATISTICAL TABLE (CONTINUED) Country, regional and global estimates of mortality among children under age 5 and children aged 5–14 years Estimates of mortality among children under age 5 and children aged 5–14 years by UNICEF regionb Under-five mortality rate (U5MR) with 90 per cent uncertainty interval Number of under-five deaths with (deaths per 1,000 live births) 90 per cent uncertainty interval (thousands) a Annual rate of reduction 1990 2018 (ARR) (per cent) 1990 2018 1990–2018 Under- Under- Lower Upper Lower Upper Lower Upper five Lower Upper five Lower Upper Region U5MR bound bound U5MR bound bound ARR bound bound deaths bound bound deaths bound bound Sub-Saharan Africa 180 176 184 78 72 87 3.0 2.6 3.3 3,857 3,785 3,941 2,869 2,678 3,207 West and Central Africa 197 191 204 97 87 112 2.5 2.0 2.9 2,031 1,970 2,096 1,845 1,656 2,129 Eastern and Southern Africa 164 160 168 57 53 65 3.8 3.3 4.1 1,827 1,786 1,874 1,024 945 1,173 Middle East and North Africa 65 63 67 22 19 26 3.9 3.3 4.3 547 533 562 220 196 257 South Asia 130 126 133 42 39 46 4.0 3.7 4.3 4,743 4,626 4,864 1,475 1,352 1,605 East Asia and Pacific 57 54 60 15 14 16 4.8 4.4 5.1 2,302 2,195 2,430 462 432 502 Latin America and Caribbean 55 53 56 16 16 18 4.3 4.0 4.5 641 622 661 172 165 184 North America 11 11 11 6 6 7 1.9 1.7 2.1 47 46 48 27 26 29 Europe and Central Asia 31 30 32 9 8 10 4.5 4.1 4.8 387 377 398 96 90 107 Eastern Europe and Central Asia 46 45 48 13 12 14 4.6 4.2 4.9 329 319 340 78 71 88 Western Europe 10 10 11 4 4 4 3.7 3.6 3.8 57 57 58 18 18 19 World 93 92 95 39 37 42 3.1 2.9 3.3 12,524 12,352 12,724 5,322 5,100 5,709 Estimates of mortality among children under age 5 and children aged 5–14 years by World Health Organization regionb Under-five mortality rate (U5MR) with 90 per cent uncertainty interval Number of under-five deaths with (deaths per 1,000 live births) 90 per cent uncertainty interval (thousands) a Annual rate of reduction 1990 2018 (ARR) (per cent) 1990 2018 1990–2018 Under- Under- Lower Upper Lower Upper Lower Upper five Lower Upper five Lower Upper Region U5MR bound bound U5MR bound bound ARR bound bound deaths bound bound deaths bound bound Africa 177 174 181 76 71 85 3.0 2.6 3.3 3,730 3,659 3,812 2,739 2,549 3,062 Americas 43 42 44 14 13 14 4.1 3.9 4.3 688 670 708 200 192 212 Eastern Mediterranean 103 100 105 47 42 54 2.8 2.3 3.2 1,372 1,342 1,404 829 741 958 Europe 31 30 32 9 8 10 4.5 4.1 4.8 388 378 399 97 90 108 South-East Asia 119 115 122 34 31 36 4.5 4.2 4.8 4,628 4,511 4,748 1,171 1,075 1,268 Western Pacific 52 48 55 12 11 13 5.3 4.8 5.7 1,714 1,609 1,837 283 260 313 World 93 92 95 39 37 42 3.1 2.9 3.3 12,524 12,352 12,724 5,322 5,100 5,709 46 STATISTICAL TABLE (CONTINUED) Country, regional and global estimates of mortality among children under age 5 and children aged 5–14 years Estimates of mortality among children under age 5 and children aged 5–14 years by UNICEF regionb (continued) Probability of dying among Sex-specific under-five Infant Neonatal Number of children aged mortality rate mortality rate mortality rate Number of deaths among 5–14 years (deaths per 1,000 live births) (deaths per Number of (deaths per neonatal children aged (deaths per 1,000 live infant deaths 1,000 live deaths 1,000 children 5–14 years births) (thousands) a births) (thousands) a aged 5 years) (thousands)a 1990 2018 Region Male Female Male Female 1990 2018 1990 2018 1990 2018 1990 2018 1990 2018 1990 2018 Sub-Saharan Africa 189 171 83 72 107 53 2,344 1,973 46 28 1,022 1,054 40 18 592 518 West and Central Africa 206 188 103 90 115 64 1,205 1,240 48 31 522 613 40 23 279 330 Eastern and Southern Africa 173 155 62 52 101 40 1,140 733 43 24 500 441 39 13 313 189 Middle East and North Africa 67 63 23 20 50 18 418 184 28 12 238 122 10 4 67 37 South Asia 127 132 43 41 92 35 3,367 1,207 59 26 2,194 909 20 6 583 211 East Asia and Pacific 60 53 16 14 43 12 1,744 383 27 8 1,102 230 10 3 340 103 Latin America and Caribbean 59 50 18 15 43 14 509 147 23 9 267 95 6 3 63 30 North America 12 10 7 6 9 5 40 24 6 3 24 15 2 1 9 6 Europe and Central Asia 34 28 10 8 25 8 311 83 14 5 175 50 4 2 54 17 Eastern Europe and Central Asia 50 42 14 11 37 11 263 68 21 6 145 39 6 2 42 13 Western Europe 12 9 4 3 9 3 48 15 6 2 30 11 2 1 13 4 World 96 91 41 36 65 29 8,733 4,000 37 18 5,022 2,476 15 7 1,708 923 Estimates of mortality among children under age 5 and children aged 5–14 years by World Health Organization regionb (continued) Probability of dying among Sex-specific under-five Infant Neonatal Number of children aged mortality rate mortality rate mortality rate Number of deaths among 5–14 years (deaths per 1,000 live births) (deaths per Number of (deaths per neonatal children aged (deaths per 1,000 live infant deaths 1,000 live deaths 1,000 children 5–14 years births) (thousands) a births) (thousands) a aged 5 years) (thousands)a 1990 2018 Region Male Female Male Female 1990 2018 1990 2018 1990 2018 1990 2018 1990 2018 1990 2018 Africa 186 168 81 70 106 52 2,273 1,889 45 27 988 1,006 39 17 573 501 Americas 47 39 15 12 34 12 548 170 18 7 291 110 5 2 73 36 Eastern Mediterranean 105 100 50 44 76 37 1,020 660 44 26 604 464 13 7 129 105 Europe 33 28 10 8 25 7 312 83 14 5 176 51 4 2 54 18 South-East Asia 117 120 34 33 84 28 3,262 960 53 20 2,089 704 20 6 650 198 Western Pacific 54 49 13 11 40 10 1,314 234 27 6 871 139 8 3 228 64 World 96 91 41 36 65 29 8,733 4,000 37 18 5,022 2,476 15 7 1,708 923 47 STATISTICAL TABLE (CONTINUED) Country, regional and global estimates of mortality among children under age 5 and children aged 5–14 years Estimates of mortality among children under age 5 and children aged 5–14 years by World Bank regionb Under-five mortality rate (U5MR) with 90 per cent uncertainty interval Number of under-five deaths with (deaths per 1,000 live births) 90 per cent uncertainty interval (thousands) a Annual rate of reduction 1990 2018 (ARR) (per cent) 1990 2018 1990–2018 Under- Under- Lower Upper Lower Upper Lower Upper five Lower Upper five Lower Upper Region U5MR bound bound U5MR bound bound ARR bound bound deaths bound bound deaths bound bound East Asia and Pacific 57 54 60 15 14 16 4.8 4.4 5.1 2,302 2,195 2,430 462 432 502 Europe and Central Asia 31 30 32 9 8 10 4.5 4.1 4.8 387 377 398 96 90 107 Latin America and the Caribbean 55 53 56 16 16 18 4.3 4.0 4.5 641 622 661 172 165 184 Middle East and North Africa 65 64 67 22 19 26 3.9 3.3 4.3 549 535 564 221 197 259 North America 11 11 11 6 6 7 1.9 1.7 2.1 47 46 48 27 26 29 South Asia 130 126 133 42 39 46 4.0 3.7 4.3 4,743 4,626 4,864 1,475 1,352 1,605 Sub-Saharan Africa 180 177 184 78 72 87 3.0 2.6 3.3 3,855 3,782 3,939 2,868 2,677 3,206 Low income 183 179 187 68 63 77 3.5 3.1 3.8 2,579 2,529 2,636 1,611 1,497 1,815 Lower-middle income 122 120 124 49 46 54 3.3 2.9 3.5 7,304 7,174 7,443 3,173 2,966 3,472 Upper-middle income 51 49 54 13 12 13 5.0 4.7 5.2 2,473 2,366 2,598 475 454 507 High income 13 12 13 5 5 5 3.3 3.1 3.4 169 164 174 63 61 65 World 93 92 95 39 37 42 3.1 2.9 3.3 12,524 12,352 12,724 5,322 5,100 5,709 Estimates of mortality among children under age 5 and children aged 5–14 years by United Nations Population Division regionb Under-five mortality rate (U5MR) with 90 per cent uncertainty interval Number of under-five deaths with (deaths per 1,000 live births) 90 per cent uncertainty interval (thousands)a Annual rate of reduction 1990 2018 (ARR) (per cent) 1990 2018 1990–2018 Under- Under- Lower Upper Lower Upper Lower Upper five Lower Upper five Lower Upper Region U5MR bound bound U5MR bound bound ARR bound bound deaths bound bound deaths bound bound More developed regions 13 13 13 5 5 5 3.3 3.1 3.4 202 200 204 71 69 74 Less developed regions 103 102 105 42 40 45 3.2 2.9 3.4 12,322 12,150 12,523 5,250 5,028 5,638 Least developed countries 175 173 178 64 60 72 3.6 3.2 3.8 3,605 3,555 3,672 1,992 1,874 2,223 Excluding least developed countries 88 86 90 35 33 38 3.3 3.0 3.5 8,714 8,542 8,902 3,255 3,053 3,540 Excluding China 116 115 118 47 45 51 3.2 2.9 3.4 10,945 10,809 11,099 5,104 4,884 5,490 Sub-Saharan Africa 182 178 186 78 73 88 3.0 2.6 3.3 3,751 3,679 3,834 2,789 2,598 3,128 Africa 165 162 168 71 67 80 3.0 2.6 3.2 4,132 4,059 4,217 2,968 2,778 3,308 Asia 89 88 92 28 27 30 4.1 3.8 4.3 7,542 7,383 7,719 2,100 1,978 2,244 Europe 15 15 16 5 5 5 4.0 3.8 4.1 144 142 146 40 38 42 Latin America and the Caribbean 55 53 56 16 16 18 4.3 4.0 4.5 641 622 661 172 165 184 Northern America 11 11 11 6 6 7 1.9 1.7 2.1 47 46 48 27 26 29 Oceania 36 34 39 21 18 25 1.9 1.2 2.6 19 17 20 14 12 17 World 93 92 95 39 37 42 3.1 2.9 3.3 12,524 12,352 12,724 5,322 5,100 5,709 Definitions Under-five mortality rate: Probability of dying between birth and exactly 5 years of age, expressed per 1,000 live births. Infant mortality rate: Probability of dying between birth and exactly 1 year of age, expressed per 1,000 live births. Neonatal mortality rate: Probability of dying in the first 28 days of life, expressed per 1,000 live births. Probability of dying among children aged 5–14 years: Probability of dying among children aged 5–14 years expressed per 1,000 children aged 5. Note: Upper and lower bounds refer to the 90 per cent uncertainty intervals for the estimates. Estimates are generated by the United Nations Inter-agency Group for Child Mortality Estimation to ensure comparability; they are not necessarily the official statistics of United Nations Member States, which may use alternative rigorous methods. a. Number of deaths are rounded to thousands. A zero indicates that the number of deaths is below 500. Unrounded number of deaths are available at for download. b. The sum of the number of deaths by region may differ from the world total because of rounding. 48 STATISTICAL TABLE (CONTINUED) Country, regional and global estimates of mortality among children under age 5 and children aged 5–14 years Estimates of mortality among children under age 5 and children aged 5–14 years by World Bank regionb (continued) Probability of dying among Sex-specific under-five Infant Neonatal Number of children aged mortality rate mortality rate mortality rate Number of deaths among 5–14 years (deaths per 1,000 live births) (deaths per Number of (deaths per neonatal children aged (deaths per 1,000 live infant deaths 1,000 live deaths 1,000 children 5–14 years births) (thousands) a births) (thousands) a aged 5 years) (thousands)a 1990 2018 Region Male Female Male Female 1990 2018 1990 2018 1990 2018 1990 2018 1990 2018 1990 2018 East Asia and Pacific 60 53 16 14 43 12 1,744 383 27 8 1,102 230 10 3 340 103 Europe and Central Asia 34 28 10 8 25 8 311 83 14 5 175 50 4 2 54 17 Latin America and the Caribbean 59 50 18 15 43 14 509 147 23 9 267 95 6 3 63 30 Middle East and North Africa 67 63 23 20 50 18 420 185 28 12 239 123 10 4 67 37 North America 12 10 7 6 9 5 40 24 6 3 24 15 2 1 9 6 South Asia 127 132 43 41 92 35 3,367 1,207 59 26 2,194 909 20 6 583 211 Sub-Saharan Africa 189 171 83 72 107 53 2,342 1,972 46 28 1,021 1,054 40 18 591 518 Low income 191 174 73 63 110 48 1,585 1,150 49 26 720 641 42 17 420 330 Lower-middle income 123 121 51 47 84 37 5,064 2,391 49 24 2,992 1,553 20 8 962 478 Upper-middle income 54 48 14 12 41 11 1,943 406 26 7 1,223 247 7 3 288 100 High income 14 11 5 5 10 4 140 53 6 3 86 35 3 1 38 15 World 96 91 41 36 65 29 8,733 4,000 37 18 5,022 2,476 15 7 1,708 923 Estimates of mortality among children under age 5 and children aged 5–14 years by United Nations Population Division regionb (continued) Probability of dying among Sex-specific under-five Infant Neonatal Number of children aged mortality rate mortality rate mortality rate Number of deaths among 5–14 years (deaths per 1,000 live births) (deaths per Number of (deaths per neonatal children aged (deaths per 1,000 live infant deaths 1,000 live deaths 1,000 children 5–14 years births) (thousands) a births) (thousands) a aged 5 years) (thousands)a 1990 2018 Region Male Female Male Female 1990 2018 1990 2018 1990 2018 1990 2018 1990 2018 1990 2018 More developed regions 15 12 6 5 11 4 168 60 7 3 103 38 3 1 45 17 Less developed regions 106 100 44 40 71 31 8,565 3,940 40 19 4,919 2,438 17 8 1,663 906 Least developed countries 183 168 69 59 108 46 2,264 1,432 52 26 1,113 821 39 14 571 371 Excluding least developed countries 89 86 36 33 63 27 6,299 2,505 38 17 3,805 1,616 13 6 1,091 535 Excluding China 119 113 50 45 79 35 7,496 3,815 43 22 4,179 2,365 20 9 1,505 865 Sub-Saharan Africa 191 172 84 72 108 53 2,276 1,917 46 28 985 1,016 40 18 575 510 Africa 172 156 76 66 100 49 2,554 2,058 43 26 1,138 1,111 35 16 623 533 Asia 90 89 29 27 65 23 5,497 1,727 41 17 3,511 1,227 14 5 977 341 Europe 17 13 6 5 13 4 120 34 8 3 74 21 3 1 33 10 Latin America and the Caribbean 59 50 18 15 43 14 509 147 23 9 267 95 6 3 63 30 Northern America 12 10 7 6 9 5 40 24 6 3 24 15 2 1 9 6 Oceania 39 33 23 19 27 17 14 11 14 10 7 7 6 4 3 2 World 96 91 41 36 65 29 8,733 4,000 37 18 5,022 2,476 15 7 1,708 923 49 Regional Classifications The regional classifications that are referred to in the report and for which aggregate data are provided in the statistical table are Sustainable Development Goal regions. Aggregates presented for member organizations of the United Nations Inter-agency Group for Child Mortality Estimation may differ and regional classifications with the same name from different member organizations (e.g., Sub-Saharan Africa) may include different countries. Whether a country belongs to the group of Least developed countries (LDC), Landlocked developing countries (LLDC) and/or Small island developing States (SIDS) is indicated in the brackets after the country name. Sub-Saharan Africa South-Eastern Asia Angola (LDC), Benin (LDC), Botswana (LLDC), Burkina Faso (LDC, Brunei Darussalam, Cambodia (LDC), Indonesia, Lao People’s Demo- LLDC), Burundi (LDC, LLDC), Cabo Verde (SIDS), Cameroon, Central cratic Republic (LDC, LLDC), Malaysia, Myanmar (LDC), Philippines, African Republic (LDC, LLDC), Chad (LDC, LLDC), Comoros (LDC, Singapore (SIDS), Thailand, Timor-Leste (LDC, SIDS), Viet Nam SIDS), Congo, Côte d’Ivoire, Democratic Republic of the Congo (LDC), Djibouti (LDC), Equatorial Guinea, Eritrea (LDC), Eswatini (LLDC), Ethiopia (LDC, LLDC), Gabon, Gambia (LDC), Ghana, Guinea (LDC), Guinea-Bissau (LDC, SIDS), Kenya, Lesotho (LDC, LLDC), Liberia Latin America and the Caribbean (LDC), Madagascar (LDC), Malawi (LDC, LLDC), Mali (LDC, LLDC), Antigua and Barbuda (SIDS), Argentina, Bahamas (SIDS), Barbados Mauritania (LDC), Mauritius (SIDS), Mozambique (LDC), Namibia, (SIDS), Belize (SIDS), Bolivia (Plurinational State of) (LLDC), Brazil, Niger (LDC, LLDC), Nigeria, Rwanda (LDC, LLDC), Sao Tome and Chile, Colombia, Costa Rica, Cuba (SIDS), Dominica (SIDS), Dominican Principe (SIDS), Senegal (LDC), Seychelles (SIDS), Sierra Leone (LDC), Republic (SIDS), Ecuador, El Salvador, Grenada (SIDS), Guatemala, Guy- Somalia (LDC), South Africa, South Sudan (LDC, LLDC), Togo (LDC), ana (SIDS), Haiti (LDC, SIDS), Honduras, Jamaica (SIDS), Mexico, Nica- Uganda (LDC, LLDC), United Republic of Tanzania (LDC), Zambia ragua, Panama, Paraguay (LLDC), Peru, Saint Kitts and Nevis (SIDS), (LDC, LLDC), Zimbabwe (LLDC) Saint Lucia (SIDS), Saint Vincent and the Grenadines (SIDS), Suriname (SIDS), Trinidad and Tobago (SIDS), Uruguay, Venezuela (Bolivarian Republic of) Northern Africa and Western Asia Northern Africa Algeria, Egypt, Libya, Morocco, Sudan (LDC), Tunisia Oceania Australia and New Zealand Australia, New Zealand Western Asia Armenia (LLDC), Azerbaijan, Bahrain, Cyprus, Georgia, Iraq, Israel, Jor- dan, Kuwait, Lebanon, Oman, Qatar, Saudi Arabia, State of Palestine, Syr- ian Arab Republic, Turkey, United Arab Emirates, Yemen (LDC) Oceania (excluding Australia and New Zealand) Cook Islands (SIDS), Fiji (SIDS), Kiribati (LDC, SIDS), Marshall Islands (SIDS), Micronesia (Federated States of) (SIDS), Nauru (SIDS), Niue (SIDS), Palau (SIDS), Papua New Guinea (SIDS), Samoa (SIDS), Solomon Central and Southern Asia Islands (LDC, SIDS), Tonga (SIDS), Tuvalu (LDC, SIDS), Vanuatu (LDC, SIDS) Central Asia Kazakhstan (LLDC), Kyrgyzstan (LLDC), Tajikistan (LLDC), Turkmeni- stan (LLDC), Uzbekistan (LLDC) Europe and Northern America Europe Albania, Andorra, Austria, Belarus, Belgium, Bosnia and Herzegovina, Southern Asia Bulgaria, Croatia, Czechia, Denmark, Estonia, Finland, France, Germany, Afghanistan (LDC, LLDC), Bangladesh (LDC), Bhutan (LLDC), India, Greece, Hungary, Iceland, Ireland, Italy, Latvia, Lithuania, Luxembourg, Iran (Islamic Republic of), Maldives (SIDS), Nepal (LDC, LLDC), Paki- Malta, Monaco, Montenegro, Netherlands, Norway, Poland, Portugal, stan, Sri Lanka Republic of Moldova (LLDC), Romania, Russian Federation, San Marino, Serbia, Slovakia, Slovenia, Spain, Sweden, Switzerland, North Macedo- nia (LLDC), Ukraine, United Kingdom of Great Britain and Northern Ireland Eastern and South-Eastern Asia Eastern Asia China, Democratic People’s Republic of Korea, Japan, Mongolia (LLDC), Northern America Republic of Korea Canada, United States of America 50 Photography credits Cover photo: © UNICEF/UN0333398/Soares Photo on page 7: © UNICEF/UN0253471/Labrador Photo on page 19: © UNICEF/UN0306422/Abdul Photo on page 20: © UNICEF/UN0152738/Bell Photo on page 23: © UNICEF/UN0289822/Viet Hung Photo on page 26: © UNICEF/UN0304583/Arcos Photo on page 51: © UNICEF/UN0318726/Diarassouba United Nations The United Nations Inter-agency Group for Child Mortality Estimation (UN IGME) was formed in 2004 to share data on child mortality, improve methods for child mortality estimation, report on progress towards child survival goals and enhance country capacity to produce timely and properly assessed estimates of child mortality. The UN IGME is led by the United Nations Children’s Fund and includes the World Health Organization, the World Bank Group and the United Nations Population Division of the Department of Economic and Social Affairs as full members. The UN IGME’s independent Technical Advisory Group, comprising leading academic scholars and independent experts in demography and biostatistics, provides technical guidance on estimation methods, technical issues and strategies for data analysis and data quality assessment. The UN IGME updates its child mortality estimates annually after reviewing newly available data and assessing data quality. This report contains the latest UN IGME estimates of child mortality at the country, regional and global levels. Country-specific estimates and the data used to derive them are available at . Suggested citation: United Nations Inter-agency Group for Child Mortality Estimation (UN IGME), ‘Levels & Trends in Child Mortality: Report 2019, Estimates developed by the United Nations Inter-agency Group for Child Mortality Estimation’, United Nations Children’s Fund, New York, 2019.