Global, regional, and national trends in under-5 mortality between 1990 and 2019 with scenario-based projections until 2030: a systematic analysis by the UN Inter-agency Group for Child Mortality Estimation.

BACKGROUND: The Sustainable Development Goals (SDGs), set in 2015 by the UN General Assembly, call for all countries to reach an under-5 mortality rate (U5MR) of at least as low as 25 deaths per 1000 livebirths and a neonatal mortality rate (NMR) of at least as low as 12 deaths per 1000 livebirths by 2030. We estimated levels and trends in under-5 mortality for 195 countries from 1990 to 2019, and conducted scenario-based projections of the U5MR and NMR from 2020 to 2030 to assess country progress in, and potential for, reaching SDG targets on child survival and the potential under-5 and neonatal deaths over the next decade. METHODS: Levels and trends in under-5 mortality are based on the UN Inter-agency Group for Child Mortality Estimation (UN IGME) database on under-5 mortality, which contains around 18 000 country-year datapoints for 195 countries-nearly 10 000 of those datapoints since 1990. The database includes nationally representative mortality data from vital registration systems, sample registration systems, population censuses, and household surveys. As with previous sets of national UN IGME estimates, a Bayesian B-spline bias-reduction model (B3) that considers the systematic biases associated with the different data source types was fitted to these data to generate estimates of under-5 (age 0-4 years) mortality with uncertainty intervals for 1990-2019 for all countries. Levels and trends in the neonatal mortality rate (0-27 days) are modelled separately as the log ratio of the neonatal mortality rate to the under-5 mortality rate using a Bayesian model. Estimated mortality rates are combined with livebirths data to calculate the number of under-5 and neonatal deaths. To assess the regional and global burden of under-5 deaths in the present decade and progress towards SDG targets, we constructed several scenario-based projections of under-5 mortality from 2020 to 2030 and estimated national, regional, and global under-5 mortality trends up to 2030 for each scenario. FINDINGS: The global U5MR decreased by 59% (90% uncertainty interval [UI] 56-61) from 93·0 (91·7-94·5) deaths per 1000 livebirths in 1990 to 37·7 (36·1-40·8) in 2019, while the annual number of global under-5 deaths declined from 12·5 (12·3-12·7) million in 1990 to 5·2 (5·0-5·6) million in 2019-a 58% (55-60) reduction. The global NMR decreased by 52% (90% UI 48-55) from 36·6 (35·6-37·8) deaths per 1000 livebirths in 1990, to 17·5 (16·6-19·0) in 2019, and the annual number of global neonatal deaths declined from 5·0 (4·9-5·2) million in 1990, to 2·4 (2·3-2·7) million in 2019, a 51% (47-54) reduction. As of 2019, 122 of 195 countries have achieved the SDG U5MR target, and 20 countries are on track to achieve the target by 2030, while 53 will need to accelerate progress to meet the target by 2030. 116 countries have reached the SDG NMR target with 16 on track, leaving 63 at risk of missing the target. If current trends continue, 48·1 million under-5 deaths are projected to occur between 2020 and 2030, almost half of them projected to occur during the neonatal period. If all countries met the SDG target on under-5 mortality, 11 million under-5 deaths could be averted between 2020 and 2030. INTERPRETATION: As a result of effective global health initiatives, millions of child deaths have been prevented since 1990. However, the task of ending all preventable child deaths is not done and millions more deaths could be averted by meeting international targets. Geographical and economic variation demonstrate the possibility of even lower mortality rates for children under age 5 years and point to the regions and countries with highest mortality rates and in greatest need of resources and action. FUNDING: Bill & Melinda Gates Foundation, US Agency for International Development.

Global, regional, and national estimates and trends in stillbirths from 2000 to 2019: a systematic assessment.

BACKGROUND: Stillbirths are a major public health issue and a sensitive marker of the quality of care around pregnancy and birth. The UN Global Strategy for Women's, Children's and Adolescents' Health (2016-30) and the Every Newborn Action Plan (led by UNICEF and WHO) call for an end to preventable stillbirths. A first step to prevent stillbirths is obtaining standardised measurement of stillbirth rates across countries. We estimated stillbirth rates and their trends for 195 countries from 2000 to 2019 and assessed progress over time. METHODS: For a systematic assessment, we created a dataset of 2833 country-year datapoints from 171 countries relevant to stillbirth rates, including data from registration and health information systems, household-based surveys, and population-based studies. After data quality assessment and exclusions, we used 1531 datapoints to estimate country-specific stillbirth rates for 195 countries from 2000 to 2019 using a Bayesian hierarchical temporal sparse regression model, according to a definition of stillbirth of at least 28 weeks' gestational age. Our model combined covariates with a temporal smoothing process such that estimates were informed by data for country-periods with high quality data, while being based on covariates for country-periods with little or no data on stillbirth rates. Bias and additional uncertainty associated with observations based on alternative stillbirth definitions and source types, and observations that were subject to non-sampling errors, were included in the model. We compared the estimated stillbirth rates and trends to previously reported mortality estimates in children younger than 5 years. FINDINGS: Globally in 2019, an estimated 2·0 million babies (90% uncertainty interval [UI] 1·9-2·2) were stillborn at 28 weeks or more of gestation, with a global stillbirth rate of 13·9 stillbirths (90% UI 13·5-15·4) per 1000 total births. Stillbirth rates in 2019 varied widely across regions, from 22·8 stillbirths (19·8-27·7) per 1000 total births in west and central Africa to 2·9 (2·7-3·0) in western Europe. After west and central Africa, eastern and southern Africa and south Asia had the second and third highest stillbirth rates in 2019. The global annual rate of reduction in stillbirth rate was estimated at 2·3% (90% UI 1·7-2·7) from 2000 to 2019, which was lower than the 2·9% (2·5-3·2) annual rate of reduction in neonatal mortality rate (for neonates aged <28 days) and the 4·3% (3·8-4·7) annual rate of reduction in mortality rate among children aged 1-59 months during the same period. Based on the lower bound of the 90% UIs, 114 countries had an estimated decrease in stillbirth rate since 2000, with four countries having a decrease of at least 50·0%, 28 having a decrease of 25·0-49·9%, 50 having a decrease of 10·0-24·9%, and 32 having a decrease of less than 10·0%. For the remaining 81 countries, we found no decrease in stillbirth rate since 2000. Of these countries, 34 were in sub-Saharan Africa, 16 were in east Asia and the Pacific, and 15 were in Latin America and the Caribbean. INTERPRETATION: Progress in reducing the rate of stillbirths has been slow compared with decreases in the mortality rate of children younger than 5 years. Accelerated improvements are most needed in the regions and countries with high stillbirth rates, particularly in sub-Saharan Africa. Future prevention of stillbirths needs increased efforts to raise public awareness, improve data collection, assess progress, and understand public health priorities locally, all of which require investment. FUNDING: Bill & Melinda Gates Foundation and the UK Foreign, Commonwealth and Development Office.

The effects of changes in distance to nearest health facility on under-5 mortality and health care utilization in rural Malawi, 1980-1998.

BACKGROUND: Despite important progress, the burden of under-5 mortality remains unacceptably high, with an estimated 5.3 million deaths in 2018. Lack of access to health care is a major risk factor for under-5 mortality, and distance to health care facilities has been shown to be associated with less access to care in multiple contexts, but few such studies have used a counterfactual approach to produce causal estimates. METHODS: We combined retrospective reports on 18,714 births between 1980 and 1998 from the 2000 Malawi Demographic and Health Survey with a 1998 health facility census that includes the date of construction for each facility, including 335 maternity or maternity/dispensary facilities built in rural areas between 1980 and 1998. We estimated associations between distance to nearest health facility and (i) under-5 mortality, using Cox proportional hazards models, and (ii) maternal health care utilization (antenatal visits prior to delivery, place of delivery, receiving skilled assistance during delivery, and receiving a check-up following delivery), using linear probability models. We also estimated the causal effect of reducing the distance to nearest facility on those outcomes, using a two-way fixed effects approach. FINDINGS: We found that greater distance was associated with higher mortality (hazard ratio 1.007 for one additional kilometer [95%CI 1.001 to 1.014]) and lower health care utilization (for one additional kilometer: 1.2 percentage point (pp) increase in homebirth [95%CI 0.8 to 1.5]; 0.8 pp. decrease in at least three antenatal visits [95% CI - 1.4 to - 0.2]; 1.2 pp. decrease in skilled assistance during delivery [95%CI - 1.6 to - 0.8]). However, we found no effects of a decrease in distance to the nearest health facility on the hazard of death before age 5 years, nor on antenatal visits prior to delivery, place of delivery, or receiving skilled assistance during delivery. We also found that reductions in distance decrease the probability that a woman receives a check-up following delivery (2.4 pp. decrease for a 1 km decrease [95%CI 0.004 to 0.044]). CONCLUSION: Reducing under-5 mortality and increasing utilization of care in rural Malawi and similar settings may require more than the construction of new health infrastructure. Importantly, the effects estimated here likely depend on the quality of health care, the availability of transportation, the demand for health services, and the underlying causes of mortality, among other factors.

Measuring and correcting bias in indirect estimates of under-5 mortality in populations affected by HIV/AIDS: a simulation study.

BACKGROUND: In populations that lack vital registration systems, under-5 mortality (U5M) is commonly estimated using survey-based approaches, including indirect methods. One assumption of indirect methods is that a mother's survival and her children's survival are not correlated, but in populations affected by HIV/AIDS this assumption is violated, and thus indirect estimates are biased. Our goal was to estimate the magnitude of the bias, and to create a predictive model to correct it. METHODS: We used an individual-level, discrete time-step simulation model to measure how the bias in indirect estimates of U5M changes under various fertility rates, mortality rates, HIV/AIDS rates, and levels of antiretroviral therapy. We simulated 4480 populations in total and measured the amount of bias in U5M due to HIV/AIDS. We also developed a generalized linear model via penalized maximum likelihood to correct this bias. RESULTS: We found that indirect methods can underestimate U5M by 0-41% in populations with HIV prevalence of 0-40%. Applying our model to 2010 survey data from Malawi and Tanzania, we show that indirect methods would underestimate U5M by up to 7.7% in those countries at that time. Our best fitting model to correct bias in U5M had a root median square error of 0.0012. CONCLUSIONS: Indirect estimates of U5M can be significantly biased in populations affected by HIV/AIDS. Our predictive model allows scholars and practitioners to correct that bias using commonly measured population characteristics. Policies and programs based on indirect estimates of U5M in populations with generalized HIV epidemics may need to be reevaluated after accounting for estimation bias.

Interventions for children with reactive attachment disorder.

Characterized by aggressive or violent behaviors, reactive attachment disorder (RAD) affects children who have been repeatedly exposed to traumatic experiences. This article discusses the underlying causes of RAD and provides insight on therapies and interventions.

Global, regional, and national mortality trends in older children and young adolescents (5-14 years) from 1990 to 2016: an analysis of empirical data.

BACKGROUND: From 1990 to 2016, the mortality of children younger than 5 years decreased by more than half, and there are plentiful data regarding mortality in this age group through which we can track global progress in reducing the under-5 mortality rate. By contrast, little is known on how the mortality risk among older children (5-9 years) and young adolescents (10-14 years) has changed in this time. We aimed to estimate levels and trends in mortality of children aged 5-14 years in 195 countries from 1990 to 2016. METHODS: In this analysis of empirical data, we expanded the United Nations Inter-agency Group for Child Mortality Estimation database containing data on children younger than 5 years with 5530 data points regarding children aged 5-14 years. Mortality rates from 1990 to 2016 were obtained from nationally representative birth histories, data on household deaths reported in population censuses, and nationwide systems of civil registration and vital statistics. These data were used in a Bayesian B-spline bias-reduction model to generate smoothed trends with 90% uncertainty intervals, to determine the probability of a child aged 5 years dying before reaching age 15 years. FINDINGS: Globally, the probability of a child dying between the ages 5 years and 15 years was 7·5 deaths (90% uncertainty interval 7·2-8·3) per 1000 children in 2016, which was less than a fifth of the risk of dying between birth and age 5 years, which was 41 deaths (39-44) per 1000 children. The mortality risk in children aged 5-14 years decreased by 51% (46-54) between 1990 and 2016, despite not being specifically targeted by health interventions. The annual number of deaths in this age group decreased from 1·7 million (1·7 million-1·8 million) to 1 million (0·9 million-1·1 million) in 1990-2016. In 1990-2000, mortality rates in children aged 5-14 years decreased faster than among children aged 0-4 years. However, since 2000, mortality rates in children younger than 5 years have decreased faster than mortality rates in children aged 5-14 years. The annual rate of reduction in mortality among children younger than 5 years has been 4·0% (3·6-4·3) since 2000, versus 2·7% (2·3-3·0) in children aged 5-14 years. Older children and young adolescents in sub-Saharan Africa are disproportionately more likely to die than those in other regions; 55% (51-58) of deaths of children of this age occur in sub-Saharan Africa, despite having only 21% of the global population of children aged 5-14 years. In 2016, 98% (98-99) of all deaths of children aged 5-14 years occurred in low-income and middle-income countries, and seven countries alone accounted for more than half of the total number of deaths of these children. INTERPRETATION: Increased efforts are required to accelerate reductions in mortality among older children and to ensure that they benefit from health policies and interventions as much as younger children. FUNDING: UN Children's Fund, Bill & Melinda Gates Foundation, United States Agency for International Development.

Correction: Assessing development assistance for child survival between 2000 and 2014: A multi-sectoral perspective.

[This corrects the article DOI: 10.1371/journal.pone.0178887.].

Using census data to measure maternal mortality: A review of recent experience.

BACKGROUND: The Sustainable Development Goals adopted by the United Nations General Assembly in 2015 (United Nations 2015) set national targets for reducing maternal mortality, putting pressure on governments of countries lacking comprehensive statistical systems to find other ways to measure it. One approach tested since the 1990s has been to collect necessary data through national population censuses. OBJECTIVE: This paper reviews maternal mortality data from the 2010 round of censuses for several countries to determine whether the census is useful for monitoring maternal mortality. METHODS: Data on births, deaths, and pregnancy-related deaths from two censuses for 10 countries was evaluated using standard methods; adjustments were applied to the reported numbers if so indicated. RESULTS: In general, the censuses underreported births moderately and underreported deaths by larger amounts; except in one case, proportions of pregnancy-related deaths appeared plausible. Adjusted estimates of the pregnancy-related mortality ratio (PRMR) were generally higher than estimates from Demographic and Health Survey sibling data or estimates of maternal mortality developed by cross-national studies. CONCLUSIONS: Analysis of recent data confirms results of earlier assessments: Census data provides imperfect but still valuable information on maternal mortality. Data requires careful assessment and often adjustment, resulting in estimates with large uncertainty. CONTRIBUTION: This paper provides additional evidence as to whether maternal mortality can usefully be measured by population censuses in countries lacking civil registration data.

Assessing development assistance for child survival between 2000 and 2014: A multi-sectoral perspective.

BACKGROUND: The majority of Countdown countries did not reach the fourth Millennium Development Goal (MDG 4) on reducing child mortality, despite the fact that donor funding to the health sector has drastically increased. When tracking aid invested in child survival, previous studies have exclusively focused on aid targeting reproductive, maternal, newborn, and child health (RMNCH). We take a multi-sectoral approach and extend the estimation to the four sectors that determine child survival: health (RMNCH and non-RMNCH), education, water and sanitation, and food and humanitarian assistance (Food/HA). METHODS AND FINDINGS: Using donor reported data, obtained mainly from the OECD Creditor Reporting System and Development Assistance Committee, we tracked the level and trends of aid (in grants or loans) disbursed to each of the four sectors at the global, regional, and country levels. We performed detailed analyses on missing data and conducted imputation with various methods. To identify aid projects for RMNCH, we developed an identification strategy that combined keyword searches and manual coding. To quantify aid for RMNCH in projects with multiple purposes, we adopted an integrated approach and produced the lower and upper bounds of estimates for RMNCH, so as to avoid making assumptions or using weak evidence for allocation. We checked the sensitivity of trends to the estimation methods and compared our estimates to that produced by other studies. Our study yielded time-series and recipient-specific annual estimates of aid disbursed to each sector, as well as their lower- and upper-bounds in 134 countries between 2000 and 2014, with a specific focus on Countdown countries. We found that the upper-bound estimates of total aid disbursed to the four sectors in 134 countries rose from US$ 22.62 billion in 2000 to US$ 59.29 billion in 2014, with the increase occurring in all income groups and regions with sub-Saharan Africa receiving the largest sum. Aid to RMNCH has experienced the fastest growth (12.4%), followed by aid to Food/HA (9.4%), education (5.1%), and water and sanitation (5.0%). With the exception of RMNCH, the average per capita aid disbursed to each sector in the 74 Countdown countries was smaller than in non-Countdown countries. While countries with a large number of child deaths tend to receive the largest amount of disbursements, non-Countdown countries with small populations usually received the highest level of per capita aid for child survival among all 134 countries. Compared to other Countdown countries, those that met MDG 4 with a high reliance on health aid received much higher per capita aid across all sectors. These findings are robust to estimation methods. CONCLUSIONS: The study suggests that to improve child survival, better targeted investments should be made in the four sectors, and aid to non-health sectors could be a possible contributor to child mortality reduction. We recommend that future studies on tracking aid for child survival go beyond the health sector and include other sectors that directly affect child survival. Investigation should also be made about the link between aid to each of the four sectors and child mortality reduction.

Testing survey-based methods for rapid monitoring of child mortality, with implications for summary birth history data.

INTRODUCTION: Under-five mortality estimates are increasingly used in low and middle income countries to target interventions and measure performance against global development goals. Two new methods to rapidly estimate under-5 mortality based on Summary Birth Histories (SBH) were described in a previous paper and tested with data available. This analysis tests the methods using data appropriate to each method from 5 countries that lack vital registration systems. SBH data are collected across many countries through censuses and surveys, and indirect methods often rely upon their quality to estimate mortality rates. METHODS AND FINDINGS: The Birth History Imputation method imputes data from a recent Full Birth History (FBH) onto the birth, death and age distribution of the SBH to produce estimates based on the resulting distribution of child mortality. DHS FBHs and MICS SBHs are used for all five countries. In the implementation, 43 of 70 estimates are within 20% of validation estimates (61%). Mean Absolute Relative Error is 17.7.%. 1 of 7 countries produces acceptable estimates. The Cohort Change method considers the differences in births and deaths between repeated Summary Birth Histories at 1 or 2-year intervals to estimate the mortality rate in that period. SBHs are taken from Brazil's PNAD Surveys 2004-2011 and validated against IGME estimates. 2 of 10 estimates are within 10% of validation estimates. Mean absolute relative error is greater than 100%. CONCLUSIONS: Appropriate testing of these new methods demonstrates that they do not produce sufficiently good estimates based on the data available. We conclude this is due to the poor quality of most SBH data included in the study. This has wider implications for the next round of censuses and future household surveys across many low- and middle- income countries.

Upgrades of poloidal and tangential x-ray imaging crystal spectrometers for temperature and rotation measurements on EAST.

During the past two years, key parts of poloidal and tangential x-ray imaging crystal spectrometers (PXCSs and TXCSs) have been upgraded. For poloidal XCSs, double-crystals of ArXVII and FeXXV were deployed. For fulfilling in situ alignment of a poloidal XCS, the beryllium window must be flexibly removed. By utilizing a design, where the beryllium window was installed in the vacuum chamber of the double-crystal, and between the double-crystal and wall of this chamber, an in situ alignment for the two spectrometers was fulfilled. Also, a new holder for the double-crystal was installed to allow for precise adjustments of azimuth angle and vertical height of the double-crystal. In order to facilitate these adjustments of double-crystal and installation of beryllium window, the chamber of the double-crystal for PXCS was upgraded from a cylinder to a cuboid. The distance between double-crystal and magnetic axis was extended from 8936 mm to 9850 mm in order to improve spatial resolution for PXCS, which is currently in the range from 1.237 mm to 4.80 mm at magnetic axis. Furthermore, a new pixelated detector (PILATUS 900K), which has a large sensitive area of 83.8 × 325.3 mm2 and which is vacuum compatible, is being implemented on the PXCS. This detector is mounted on a rail, so that its position can be changed by 50 mm to effectively record spectra of He-like argon and He-like iron (ArXVII and FeXXV). Similarly, a rail, which allows detector movement by 50 mm, was also installed in TXCS to alternatively record spectra of ArXVII and ArXVIII. Presently, the operation duration of PXCS and TXCS has been upgraded to hundreds of seconds in one shot. Ti- and uϕ-profiles measured by TXCS and charge exchange recombination spectroscopy (CXRS) were compared and found to be in good agreement.

Data on survival of recent births as a source of child mortality estimates in the developing world: An assessment of census data.

In many less developed countries, household surveys collect full and summary birth histories to provide estimates of child mortality. However, full birth histories are expensive to collect and cannot provide precise estimates for small areas, and summary birth histories only provide past child mortality trends. A simple method that provides estimates for the most recent past uses questions about the survival of recent births in censuses or large household surveys. This study examines such data collected by 45 censuses and shows that on average they tend to underestimate under-5 mortality in comparison with alternative estimates, albeit with wide variations. In addition, the high non-sampling uncertainty in this approach precludes its use in providing robust estimates of child mortality at the country level. Given these findings, we suggest that questions about the survival of recent births to collect data on child mortality not be included in census questionnaires.

Voltage-gated calcium channel autoimmune cerebellar degeneration: Case and study of cytotoxicity.

OBJECTIVES: To describe response to treatment in a patient with autoantibodies against voltage-gated calcium channels (VGCCs) who presented with autoimmune cerebellar degeneration and subsequently developed Lambert-Eaton myasthenic syndrome (LEMS), and to study the effect of the patient's autoantibodies on Purkinje cells in rat cerebellar slice cultures. METHODS: Case report and study of rat cerebellar slice cultures incubated with patient VGCC autoantibodies. RESULTS: A 53-year-old man developed progressive incoordination with ataxic speech. Laboratory evaluation revealed VGCC autoantibodies without other antineuronal autoantibodies. Whole-body PET scans 6 and 12 months after presentation detected no malignancy. The patient improved significantly with IV immunoglobulin G (IgG), prednisone, and mycophenolate mofetil, but worsened after IV IgG was halted secondary to aseptic meningitis. He subsequently developed weakness with electrodiagnostic evidence of LEMS. The patient's IgG bound to Purkinje cells in rat cerebellar slice cultures, followed by neuronal death. Reactivity of the patient's autoantibodies with VGCCs was confirmed by blocking studies with defined VGCC antibodies. CONCLUSIONS: Autoimmune cerebellar degeneration associated with VGCC autoantibodies may precede onset of LEMS and may improve with immunosuppressive treatment. Binding of anti-VGCC antibodies to Purkinje cells in cerebellar slice cultures may be followed by cell death. Patients with anti-VGCC autoantibodies may be at risk of irreversible neurologic injury over time, and treatment should be initiated early.

Deep Neck Fibromatosis After Diskectomy and Cervical Fusion: Case Series and Review of the Literature.

OBJECTIVE: The objective of our study was to report head and neck deep fibromatosis as part of the differential diagnosis of a firm painful neck mass after cervical fusion and diskectomy. CONCLUSION: Although they are rare tumors, fibromatosis tumors or desmoid tumors should be considered in a patient with a painful neck mass; a history of cervical spine surgery; and MRI findings showing a large, avidly enhancing, heterogeneous mass adjacent to surgical hardware that is hyperintense on T2-weighted imaging.

Malawi and Millennium Development Goal 4: a Countdown to 2015 country case study.

BACKGROUND: Several years in advance of the 2015 endpoint for the Millennium Development Goals (MDGs), Malawi was already thought to be one of the few countries in sub-Saharan Africa likely to meet the MDG 4 target of reducing under-5 mortality by two-thirds between 1990 and 2015. Countdown to 2015 therefore selected the Malawi National Statistical Office to lead an in-depth country case study, aimed mainly at explaining the country's success in improving child survival. METHODS: We estimated child and neonatal mortality for the years 2000-14 using five district-representative household surveys. The study included recalculation of coverage indicators for that period, and used the Lives Saved Tool (LiST) to attribute the child lives saved in the years from 2000 to 2013 to various interventions. We documented the adoption and implementation of policies and programmes affecting the health of women and children, and developed estimates of financing. FINDINGS: The estimated mortality rate in children younger than 5 years declined substantially in the study period, from 247 deaths (90% CI 234-262) per 1000 livebirths in 1990 to 71 deaths (58-83) in 2013, with an annual rate of decline of 5·4%. The most rapid mortality decline occurred in the 1-59 months age group; neonatal mortality declined more slowly (from 50 to 23 deaths per 1000 livebirths), representing an annual rate of decline of 3·3%. Nearly half of the coverage indicators have increased by more than 20 percentage points between 2000 and 2014. Results from the LiST analysis show that about 280,000 children's lives were saved between 2000 and 2013, attributable to interventions including treatment for diarrhoea, pneumonia, and malaria (23%), insecticide-treated bednets (20%), vaccines (17%), reductions in wasting (11%) and stunting (9%), facility birth care (7%), and prevention and treatment of HIV (7%). The amount of funding allocated to the health sector has increased substantially, particularly to child health and HIV and from external sources, but remains below internationally agreed targets. Key policies to address the major causes of child mortality and deliver high-impact interventions at scale throughout Malawi began in the late 1990s and intensified in the latter half of the 2000s and into the 2010s, backed by health-sector-wide policies to improve women's and children's health. INTERPRETATION: This case study confirmed that Malawi had achieved MDG 4 for child survival by 2013. Our findings suggest that this was achieved mainly through the scale-up of interventions that are effective against the major causes of child deaths (malaria, pneumonia, and diarrhoea), programmes to reduce child undernutrition and mother-to-child transmission of HIV, and some improvements in the quality of care provided around birth. The Government of Malawi was among the first in sub-Saharan Africa to adopt evidence-based policies and implement programmes at scale to prevent unnecessary child deaths. Much remains to be done, building on this success and extending it to higher proportions of the population and targeting continued high neonatal mortality rates. FUNDING: Bill & Melinda Gates Foundation, WHO, The World Bank, Government of Australia, Government of Canada, Government of Norway, Government of Sweden, Government of the UK, and UNICEF.

Independent Evaluation of the integrated Community Case Management of Childhood Illness Strategy in Malawi Using a National Evaluation Platform Design.

We evaluated the impact of integrated community case management of childhood illness (iCCM) on careseeking for childhood illness and child mortality in Malawi, using a National Evaluation Platform dose-response design with 27 districts as units of analysis. "Dose" variables included density of iCCM providers, drug availability, and supervision, measured through a cross-sectional cellular telephone survey of all iCCM-trained providers. "Response" variables were changes between 2010 and 2014 in careseeking and mortality in children aged 2-59 months, measured through household surveys. iCCM implementation strength was not associated with changes in careseeking or mortality. There were fewer than one iCCM-ready provider per 1,000 under-five children per district. About 70% of sick children were taken outside the home for care in both 2010 and 2014. Careseeking from iCCM providers increased over time from about 2% to 10%; careseeking from other providers fell by a similar amount. Likely contributors to the failure to find impact include low density of iCCM providers, geographic targeting of iCCM to "hard-to-reach" areas although women did not identify distance from a provider as a barrier to health care, and displacement of facility careseeking by iCCM careseeking. This suggests that targeting iCCM solely based on geographic barriers may need to be reconsidered.

Community-Based Health Financing and Child Stunting in Rural Rwanda.

OBJECTIVES: We analyzed the likelihood of rural children (aged 6-24 months) being stunted according to whether they were enrolled in Mutuelles, a community-based health-financing program providing health insurance to rural populations and granting them access to health care, including nutrition services. METHODS: We retrieved health facility data from the District Health System Strengthening Tool and calculated the percentage of rural health centers that provided nutrition-related services required by Mutuelles' minimum service package. We used data from the 2010 Rwanda Demographic and Health Survey and performed multilevel logistic analysis to control for clustering effects and sociodemographic characteristics. The final sample was 1061 children. RESULTS: Among 384 rural health centers, more than 90% conducted nutrition-related campaigns and malnutrition screening for children. Regardless of poverty status, the risk of being stunted was significantly lower (odds ratio = 0.60; 95% credible interval = 0.41, 0.83) for Mutuelles enrollees. This finding was robust to various model specifications (adjusted for Mutuelles enrollment, poverty status, other variables) or estimation methods (fixed and random effects). CONCLUSIONS: This study provides evidence of the effectiveness of Mutuelles in improving child nutrition status and supported the hypothesis about the role of Mutuelles in expanding medical and nutritional care coverage for children.

Monitoring Change in Child Mortality through Household Surveys.

BACKGROUND: Most low- and middle-income countries lack fully functional civil registration systems. Measures of under-five mortality are typically derived from periodic household surveys collecting detailed information from women on births and child deaths. However, such surveys are expensive and are not appropriate for monitoring short-term changes in child mortality. We explored and tested the validity of two new analysis methods for less-expensive summary histories of births and child deaths for such monitoring in five African countries. METHODS AND FINDINGS: The first method we explored uses individual-level survey data on births and child deaths to impute full birth histories from an earlier survey onto summary histories from a more recent survey. The second method uses cohort changes between two surveys in the average number of children born and the number of children dead by single year of age to estimate under-five mortality for the inter-survey period. The first method produces acceptable annual estimates of under-five mortality for two out of six applications to available data sets; the second method produced an acceptable estimate in only one of five applications, though none of the applications used ideal data sets. CONCLUSIONS: The methods we tested were not able to produce consistently good quality estimates of annual under-five mortality from summary birth history data. The key problem we identified was not with the methods themselves, but with the underlying quality of the summary birth histories. If summary birth histories are to be included in general household surveys, considerable emphasis must be placed on quality control.