Case Study

Mapping 123 million neonatal, infant and child deaths between 2000 and 2017

Burstein, R., Henry, N.J., Collison, M.L. et al.
Nature Research Journal
Publication Year:
May 12, 2020
  • SDG 3 - Good Health and Well-Being

This study enables the identification of high-mortality clusters, patterns of progress and geographical inequalities to inform appropriate investments and implementations that will help to improve the health of all populations.


Since 2000, many countries have achieved considerable success in improving child survival, but localized progress remains unclear. To inform efforts towards United Nations Sustainable Development Goal 3.2—to end preventable child deaths by 2030—we need consistently estimated data at the subnational level regarding child mortality rates and trends. Here we quantified, for the period 2000–2017, the subnational variation in mortality rates and number of deaths of neonates, infants and children under 5 years of age within 99 low- and middle-income countries using a geostatistical survival model. We estimated that 32% of children under 5 in these countries lived in districts that had attained rates of 25 or fewer child deaths per 1,000 live births by 2017, and that 58% of child deaths between 2000 and 2017 in these countries could have been averted in the absence of geographical inequality. This study enables the identification of high-mortality clusters, patterns of progress and geographical inequalities to inform appropriate investments and implementations that will help to improve the health of all populations.


Gains in child survival have long served as an important proxy measure for improvements in overall population health and development1,2. Global progress in reducing child deaths has been heralded as one of the greatest success stories of global health3. The annual global number of deaths of children under 5 years of age (under 5)4 has declined from 19.6 million in 1950 to 5.4 million in 2017. Nevertheless, these advances in child survival have been far from universally achieved, particularly in low- and middle-income countries (LMICs)4. Previous subnational child mortality assessments at the first (that is, states or provinces) or second (that is, districts or counties) administrative level indicate that extensive geographical inequalities persist5,6,7.

Progress in child survival also diverges across age groups4. Global reductions in mortality rates of children under 5—that is, the under-5 mortality rate (U5MR)—among post-neonatal age groups are greater than those for mortality of neonates (0–28 days)4,8. It is relatively unclear how these age patterns are shifting at a more local scale, posing challenges to ensuring child survival. To pursue the ambitious Sustainable Development Goal (SDG) of the United Nations9 to “end preventable deaths of newborns and children under 5” by 2030, it is vital for decision-makers at all levels to better understand where, and at what ages, child survival remains most tenuous.

Precision public health and child mortality

Country-level estimates facilitate international comparisons but mask important geographical heterogeneity. Previous assessments of mortality of children under 5 have noted significant within-country heterogeneity, particularly in sub-Saharan Africa5,7,10,11,12,13,14, as well as in Brazil15, Iran16 and China17. Understanding public health risks at more granular subpopulation levels is central to the emerging concept of precision public health18, which uses “the best available data to target more effectively and efficiently interventions…to those most in need”18. Efforts to produce high-resolution estimates of mortality of children under 5, determinants at scales that cover the multiple countries are emerging, including for vaccine coverage19,20, malaria21, diarrhoea22 and child growth failure23,24. In a previous study, we produced comprehensive estimates of African child mortality rates at a 5 × 5-km scale for 5-year intervals5. For areas outside of Africa, in which 72% of the world’s children live and 46% of global child deaths occurred in 20174, subnational heterogeneity remains mostly undescribed25.

Here we produce estimates of death counts and mortality rates of children under 5, infants (under 1 years of age) and neonates (0–28 days) in 99 countries at policy-relevant subnational scales (first and second administrative levels) for each year from 2000 to 2017. We fit a geostatistical discrete hazards model to a large dataset that is composed of 467 geo-referenced household surveys and censuses, representing approximately 15.9 million births and 1.1 million deaths of children from 2000 to 2017. Our model includes socioeconomic, environmental and health-related spatial covariates with known associations to child mortality and uses a Gaussian process random effect to exploit the correlation between data points near each other across dimensions of space, time and age group, which helps to mitigate the limitations associated with data sparsity in our estimations. For this study, we report U5MR as the expected number of deaths per 1,000 live births, reflecting the probability of dying before the age of 5 for a given location and year.

Unequal rates of child mortality

The risk of a newborn dying before their fifth birthday varies tremendously based on where in the world, and within their country, they are born. Across the 99 countries in this study, we estimate that U5MR varied as much as 24-fold at the national level in 2017, with the highest rate in the Central African Republic of 123.9 deaths (95% uncertainty interval, 104.9–148.2) per 1,000 live births, and the lowest rate in Cuba of 5.1 deaths (4.4–6.0)4. We observed large subnational variation within countries in which overall U5MR was either high or comparatively low. For example, in Vietnam, rates across second administrative units (henceforth referred to as ‘units’) varied 5.7-fold, from 6.9 (4.6–9.8) in the Tenth District in Hồ Chí Minh City to 39.7 (28.1–55.6) in Mường Tè District in the Northwest region (Figs. 1b2).


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