Multilevel analysis of healthcare utilization for childhood diarrhea in high under five mortality countries.

Globally, 4.9 million under-five deaths occurred before celebrating their fifth birthday. Four in five under-five deaths were recorded in sub-Saharan Africa and Southern Asia. Childhood diarrhea is one of the leading causes of death and is accountable for killing around 443,832 children every year. Despite healthcare utilization for childhood diarrhea has a significant effect on the reduction of childhood mortality and morbidity, most children die due to delays in seeking healthcare. Therefore, this study aimed to assess healthcare utilization for childhood diarrhea in the top high under-five mortality countries. This study used secondary data from 2013/14 to 2019 demographic and health surveys of 4 top high under-five mortality countries. A total weighted sample of 7254 mothers of under-five children was included. A multilevel binary logistic regression was employed to identify the associated factors of healthcare utilization for childhood diarrhea. The statistical significance was declared at a p-value less than 0.05 with a 95% confidence interval. The overall magnitude of healthcare utilization for childhood diarrhea in the top high under-five mortality countries was 58.40% (95% CI 57.26%, 59.53%). Partner/husband educational status, household wealth index, media exposure, information about oral rehydration, and place of delivery were the positive while the number of living children were the negative predictors of healthcare utilization for childhood diarrhea in top high under-five mortality countries. Besides, living in different countries compared to Guinea was also an associated factor for healthcare utilization for childhood diarrhea. More than four in ten children didn't receive health care for childhood diarrhea in top high under-five mortality countries. Thus, to increase healthcare utilization for childhood diarrhea, health managers and policymakers should develop strategies to improve the household wealth status for those with poor household wealth index. The decision-makers and program planners should also work on media exposure and increase access to education. Further research including the perceived severity of illness and ORS knowledge-related factors of healthcare utilization for childhood diarrhea should also be considered by other researchers.

Evidence of health system resilience in primary health care for preventing under-five mortality in Rwanda and Bangladesh: Lessons from an implementation study during the Millennium Development Goal period and the early period of COVID-19.

Background: The coronavirus disease 2019 (COVID-19) pandemic led to disruptions of health service delivery in many countries; some were more resilient in either limiting or rapidly responding to the disruption than others. We used mixed methods implementation research to understand factors and strategies associated with resiliency in Rwanda and Bangladesh, focussing on how evidence-based interventions targeting amenable under-five mortality that had been used during the Millennium Development Goal (MDG) period (2000-15) were maintained during the early period of COVID-19. Methods: We triangulated data from three sources - a desk review of available documents, existing quantitative data on evidence-based intervention coverage, and key informant interviews - to perform a comparative analysis using multiple case studies methodology, comparing contextual factors (barriers or facilitators), implementation strategies (existing from 2000-15, new, or adapted), and implementation outcomes across the two countries. We also analysed which health system resiliency capabilities were present in the two countries. Results: Both countries experienced many of the same facilitators for resiliency of evidence-based interventions for children under five, as well as new, pandemic-specific barriers during the early COVID-19 period (March to December 2020) that required targeted implementation strategies in response. Common facilitators included leadership and governance and a culture of accountability, while common barriers included movement restrictions, workload, and staff shortages. We saw a continuity of implementation strategies that had been associated with success in care delivery during the MDG period, including data use for monitoring and decision-making, as well as building on community health worker programmes for community-based health care delivery. New or adapted strategies used in responding to new barriers included the expanded use of digital platforms. We found implementation outcomes and strong resilience capabilities, including awareness and adaptiveness, which were related to pre-existing facilitators and implementation strategies (continued and new). Conclusions: The strategies and contextual factors Rwanda and Bangladesh leveraged to build 'everyday resilience' before COVID-19, i.e. during the MDG period, likely supported the maintained delivery of the evidence-based interventions targeting under-five mortality during the early stages of the pandemic. Expanding our understanding of pre-existing factors and strategies that contributed to resilience before and during the pandemic is important to support other countries' efforts to incorporate 'everyday resilience' into their health systems.

U-shaped association between triglyceride-glucose index and all-cause mortality among critically ill pediatrics: a population-based retrospective cohort study.

BACKGROUND: Previous studies have shown that an elevated triglyceride-glucose (TyG) index was associated with all-cause mortality in both general adult individuals and critically ill adult patients. However, the relationship between the TyG index and clinical prognosis in pediatric patients admitted to the intensive care unit (ICU) remains unknown. We aimed to investigate the association of the TyG index with in-hospital all-cause mortality in critically ill pediatric patients. METHODS: A total of 5706 patients in the Pediatric Intensive Care database were enrolled in this study. The primary outcome was 30-day in-hospital all-cause mortality, and secondary outcome was 30-day in-ICU all-cause mortality. The restricted cubic spline (RCS) curves and two-piecewise multivariate Cox hazard regression models were performed to explore the relationship between the TyG index and outcomes. RESULTS: The median age of the study population was 20.5 [interquartile range (IQR): 4.8, 63.0] months, and 3269 (57.3%) of the patients were male. The mean TyG index level was 8.6 ± 0.7. A total of 244 (4.3%) patients died within 30 days of hospitalization during a median follow-up of 11 [7, 18] days, and 236 (4.1%) patients died in ICU within 30 days of hospitalization during a median follow-up of 6 [3, 11] days. The RCS curves indicated a U-shape association between the TyG index and 30-day in-hospital and in-ICU all-cause mortality (both P values for non-linear < 0.001). The risk of 30-day in-hospital all-cause mortality was negatively correlated with the TyG index until it bottoms out at 8.6 (adjusted hazard ratio [HR], 0.72, 95% confidence interval [CI] 0.55-0.93). However, when the TyG index was higher than 8.6, the risk of primary outcome increased significantly (adjusted HR, 1.51, 95% CI 1.16-1.96]). For 30-day in-ICU all-cause mortality, we also found a similar relationship (TyG < 8.6: adjusted HR, 0.75, 95% CI 0.57-0.98; TyG ≥ 8.6: adjusted HR, 1.42, 95% CI 1.08-1.85). Those results were consistent in subgroups and various sensitivity analysis. CONCLUSIONS: Our study showed that the association between the TyG index and 30-day in-hospital and in-ICU all-cause mortality was nonlinear U-shaped, with a cutoff point at the TyG index of 8.6 in critically ill pediatric patients. Our findings suggest that the TyG index may be a novel and important factor for the short-term clinical prognosis in pediatric patients.

Trend of Mortality Due to Congenital Anomalies in Children Younger Than 5 Years in Eastern China, 2012-2021: Surveillance Data Analysis.

BACKGROUND: As one of the leading causes of child mortality, deaths due to congenital anomalies (CAs) have been a prominent obstacle to meet Sustainable Development Goal 3.2. OBJECTIVE: We conducted this study to understand the death burden and trend of under-5 CA mortality (CAMR) in Zhejiang, one of the provinces with the best medical services and public health foundations in Eastern China. METHODS: We used data retrieved from the under-5 mortality surveillance system in Zhejiang from 2012 to 2021. CAMR by sex, residence, and age group for each year was calculated and standardized according to 2020 National Population Census sex- and residence-specific live birth data in China. Poisson regression models were used to estimate the annual average change rate (AACR) of CAMR and to obtain the rate ratio between subgroups after adjusting for sex, residence, and age group when appropriate. RESULTS: From 2012 to 2021, a total of 1753 children died from CAs, and the standardized CAMR declined from 121.2 to 62.6 per 100,000 live births with an AACR of -9% (95% CI -10.7% to -7.2%; P<.001). The declining trend was also observed in female and male children, urban and rural children, and neonates and older infants, and the AACRs were -9.7%, -8.5%, -8.5%, -9.2%, -12%, and -6.3%, respectively (all P<.001). However, no significant reduction was observed in children aged 1-4 years (P=.22). Generally, the CAMR rate ratios for male versus female children, rural versus urban children, older infants versus neonates, and older children versus neonates were 1.18 (95% CI 1.08-1.30; P<.001), 1.20 (95% CI 1.08-1.32; P=.001), 0.66 (95% CI 0.59-0.73; P<.001), and 0.20 (95% CI 0.17-0.24; P<.001), respectively. Among all broad CA groups, circulatory system malformations, mainly deaths caused by congenital heart diseases, accounted for 49.4% (866/1753) of deaths and ranked first across all years, although it declined yearly with an AACR of -9.8% (P<.001). Deaths due to chromosomal abnormalities tended to grow in recent years, although the AACR was not significant (P=.90). CONCLUSIONS: CAMR reduced annually, with cardiovascular malformations ranking first across all years in Zhejiang, China. Future research and practices should focus more on the prevention, early detection, long-term management of CAs and comprehensive support for families with children with CAs to improve their survival chances.

Child drowning mortality in Israel: Trends and measures for prevention.

INTRODUCTION: In this study, we use the media-based database of Beterem-Safe Kids Israel, to provide a 15-year review of unintentional fatal childhood drowning in Israel, between 2008 and 2022. METHOD: It total, we identified 257 cases of child mortality due to drowning during this period. RESULTS: Our results demonstrate a gradual rise in childhood mortality due to drowning, from 72 cases in 2008-2012, to 85 cases in 2013-2017, and to 100 cases in 2018-2022. Especially worth noting is the increase in childhood drowning in domestic swimming pools. We point to a link between low socioeconomic status and cases of drowning, showing that the risk of drowning extends beyond a mere matter of caregiver inattention. We recommend a series of regulatory and legislative steps to reduce fatal childhood drowning, including fencing built around domestic swimming pools, extending lifeguard activity hours, adding declared beaches, forming programs of safe behavior in water environments for adolescents, and establishing swimming lessons during the 2nd grade, for all populations. We further recommend that a special focus will be put in municipalities situated at the bottom of the socioeconomic index.

Trends in maternal and child health in China and its urban and rural areas from 1991 to 2020: a joinpoint regression model.

The long-term trends in maternal and child health (MCH) in China and the national-level factors that may be associated with these changes have been poorly explored. This study aimed to assess trends in MCH indicators nationally and separately in urban and rural areas and the impact of public policies over a 30‒year period. An ecological study was conducted using data on neonatal mortality rate (NMR), infant mortality rate (IMR), under-five mortality rate (U5MR), and maternal mortality ratio (MMR) nationally and separately in urban and rural areas in China from 1991 to 2020. Joinpoint regression models were used to estimate the annual percentage changes (APC), average annual percentage changes (AAPC) with 95% confidence intervals (CIs), and mortality differences between urban and rural areas. From 1991 to 2020, maternal and child mortalities in China gradually declined (national AAPC [95% CI]: NMRs - 7.7% [- 8.6%, - 6.8%], IMRs - 7.5% [- 8.4%, - 6.6%], U5MRs - 7.5% [- 8.5%, - 6.5%], MMRs - 5.0% [- 5.7%, - 4.4%]). However, the rate of decline nationally in child mortality slowed after 2005, and in maternal mortality after 2013. For all indicators, the decline in mortality was greater in rural areas than in urban areas. The AAPCs in rate differences between rural and urban areas were - 8.5% for NMRs, - 8.6% for IMRs, - 7.7% for U5MRs, and - 9.6% for MMRs. The AAPCs in rate ratios (rural vs. urban) were - 1.2 for NMRs, - 2.1 for IMRs, - 1.7 for U5MRs, and - 1.9 for MMRs. After 2010, urban‒rural disparity in MMR did not diminish and in NMR, IMR, and U5MR, it gradually narrowed but persisted. MCH indicators have declined at the national level as well as separately in urban and rural areas but may have reached a plateau. Urban‒rural disparities in MCH indicators have narrowed but still exist. Regular analyses of temporal trends in MCH are necessary to assess the effectiveness of measures for timely adjustments.

Practical quality improvement changes for a low-resourced pediatric unit.

Background: This work describes a sustainable and replicable initiative to optimize multi-disciplinary care and uptake of clinical best practices for patients in a pediatric intensive care unit in Low/Middle Income Countries and to understand the various factors that may play a role in the reduction in child mortality seen after implementation of the Quality Improvement Initiative. Methods: This was a longitudinal assessment of a quality improvement program with the primary outcome of intubated pediatric patient mortality. The program was assessed 36 months following implementation of the quality improvement intervention using a t-test with linear regression to control for co-variates. An Impact Pathway model was developed to describe potential pathways for improvement, and context was added with an exploratory analysis of adoption of the intervention and locally initiated interventions. Results: 147 patients were included in the sustainability cohort. Comparing the initial post-implementation cohort to the sustainability cohort, the overall PICU unexpected extubations per 100 days mechanical ventilation decreased significantly from baseline (6.98) to the first year post intervention (3.52; p < 0.008) but plateaued without further significant decrease in the final cohort (3.0; p = 0.73), whereas the mortality decreased from 22.4 (std 0.42) to 9.5% (std 0.29): p value: 0.002 (confidence intervals: 0.05;0.21). The regression model that examined age, sex, diagnosis and severity of illness (via aggregate Pediatric Risk of Mortality (PRISM) scores between epochs) yielded an adjusted R-squared (adjusting for the number of predictors) value of 0.046, indicating that approximately 4.6% of the variance in mortality was explained by the predictors included in the model. The overall significance of the regression model was supported by an F-statistic of 3.198 (p = 0.00828). age, weight, diagnosis, and severity of illness. 15 new and locally driven quality practices were observed in the PICU compared to the initial post-implementation time period. The Impact Pathway model suggested multiple unique potential pathways connecting the improved patient outcomes with the intervention components. Conclusion: Sustained improvements were seen in the care of intubated pediatric patients. While some of this improvement may be attributable to the intervention, it appears likely that the change is multifactorial, as evidenced by a significant number of new quality improvement projects initiated by the local clinical team. Although currently limited by available data, the use of Driver Diagram and Impact Pathway models demonstrates several proposed causal pathways and holds potential for further elucidating the complex dynamics underlying such improvements.

Estimating 1a0 and 4a1 in a Life Table: A Model Approach Based on Newly Collected Data.

The average age of infant deaths, a10, and the average number of years lived-in the age interval-by those dying between ages 1 and 5, a41, are important quantities allowing the construction of any life table including these ages. In many applications, the direct calculation of these parameters is not possible, so they are estimated using the infant mortality rate-or the death rate from 0 to 1-as a predictor. Existing methods are general approximations that do not consider the full variability in the age patterns of mortality below the age of 5. However, at the same level of mortality, under-five deaths can be more or less concentrated during the first weeks and months of life, thus resulting in very different values of a10 and a41. This article proposes an indirect estimation of these parameters by using a recently developed model of under-five mortality and taking advantage of a new, comprehensive database by detailed age-which is used for validation. The model adapts to a variety of inputs (e.g., rates, probabilities, or the proportion of deaths by sex or for both sexes combined), providing more flexibility for the users and increasing the precision of the estimates. This fresh perspective consolidates a new method that outperforms all previous approaches.

Action against birth defects: if not now, when?

BACKGROUND: More children are surviving through interventions to address the infectious causes of under-5 mortality; subsequently, the proportion of deaths caused by birth defects is increasing. Prevention, diagnosis, treatment and care interventions for birth defects are available but are needed where the burden is highest, low-and-middle-income countries. OBJECTIVES: A selection of birth defect focused publications, conferences, and World Health Assembly resolutions from 2000 to 2017 show that global efforts were made to raise the profile of birth defects in global public health. However, recent donor support and national government interest has waned. Without concerted global action to improve primary prevention and care for children born with birth defects, the Sustainable Development Goal targets for child survival will not be met. RESULTS: Birth defects make up 8% and 10% of global under-5 and neonatal deaths respectively, making them significant contributors to preventable loss of life for children. Survivors face long-term morbidity and lifelong disability which compounds the health and economic woes of individuals, families, communities and society as a whole. Demographic changes in sub-Saharan Africa portend a growing number of births with 1.6 billion projected from 2021 to 2050. More births and better survival without effective prevention and treatment for birth defects translates into more mortality and disability from birth defects. CONCLUSIONS: We recommend interventions for prevention of birth defects. These are evidenced-based and affordable, but require low- and middle-income countries to strengthened their health systems. Action against birth defects now will prevent premature deaths and long-term disability, and lead to stronger, more resilient health systems.

Prolonged mass azithromycin distributions and macrolide resistance determinants among preschool children in Niger: A sub-study of a cluster-randomized trial (MORDOR).

BACKGROUND: Randomized controlled trials found that twice-yearly mass azithromycin administration (MDA) reduces childhood mortality, presumably by reducing infection burden. World Health Organization (WHO) issued conditional guidelines for mass azithromycin administration in high-mortality settings in sub-Saharan Africa given concerns for antibiotic resistance. While prolonged twice-yearly MDA has been shown to increase antibiotic resistance in small randomized controlled trials, the objective of this study was to determine if macrolide and non-macrolide resistance in the gut increases with the duration of azithromycin MDA in a larger setting. METHODS AND FINDINGS: The Macrolide Oraux pour Réduire les Décès avec un Oeil sur la Résistance (MORDOR) study was conducted in Niger from December 2014 to June 2020. It was a cluster-randomized trial of azithromycin (A) versus placebo (P) aimed at evaluating childhood mortality. This is a sub-study in the MORDOR trial to track changes in antibiotic resistance after prolonged azithromycin MDA. A total of 594 communities were eligible. Children 1 to 59 months in 163 randomly chosen communities were eligible to receive treatment and included in resistance monitoring. Participants, staff, and investigators were masked to treatment allocation. At the conclusion of MORDOR Phase I, by design, all communities received an additional year of twice-yearly azithromycin treatments (Phase II). Thus, at the conclusion of Phase II, the treatment history (1 letter per 6-month period) for the participating communities was either (PP-PP-AA) or (AA-AA-AA). In Phase III, participating communities were then re-randomized to receive either another 3 rounds of azithromycin or placebo, thus resulting in 4 treatment histories: Group 1 (AA-AA-AA-AA-A, N = 51), Group 2 (PP-PP-AA-AA-A, N = 40), Group 3 (AA-AA-AA-PP-P, N = 27), and Group 4 (PP-PP-AA-PP-P, N = 32). Rectal swabs from each child (N = 5,340) were obtained 6 months after the last treatment. Each child contributed 1 rectal swab and these were pooled at the community level, processed for DNA-seq, and analyzed for genetic resistance determinants. The primary prespecified outcome was macrolide resistance determinants in the gut. Secondary outcomes were resistance to beta-lactams and other antibiotic classes. Communities recently randomized to azithromycin (groups 1 and 2) had significantly more macrolide resistance determinants than those recently randomized to placebo (groups 3 and 4) (fold change 2.18, 95% CI 1.5 to 3.51, Punadj < 0.001). However, there was no significant increase in macrolide resistance in communities treated 4.5 years (group 1) compared to just the most recent 2.5 years (group 2) (fold change 0.80, 95% CI 0.50 to 1.00, Padj = 0.010), or between communities that had been treated for 3 years in the past (group 3) versus just 1 year in the past (group 4) (fold change 1.00, 95% CI 0.78 to 2.35, Padj = 0.52). We also found no significant differences for beta-lactams or other antibiotic classes. The main limitations of our study were the absence of phenotypic characterization of resistance, no complete placebo arm, and no monitoring outside of Niger limiting generalizability. CONCLUSIONS: In this study, we observed that mass azithromycin distribution for childhood mortality among preschool children in Niger increased macrolide resistance determinants in the gut but that resistance may plateau after 2 to 3 years of treatment. Co-selection to other classes needs to be monitored. TRIAL REGISTRATION: NCT02047981 https://classic.clinicaltrials.gov/ct2/show/NCT02047981.

Contribution of vaccination to improved survival and health: modelling 50 years of the Expanded Programme on Immunization.

BACKGROUND: WHO, as requested by its member states, launched the Expanded Programme on Immunization (EPI) in 1974 to make life-saving vaccines available to all globally. To mark the 50-year anniversary of EPI, we sought to quantify the public health impact of vaccination globally since the programme's inception. METHODS: In this modelling study, we used a suite of mathematical and statistical models to estimate the global and regional public health impact of 50 years of vaccination against 14 pathogens in EPI. For the modelled pathogens, we considered coverage of all routine and supplementary vaccines delivered since 1974 and estimated the mortality and morbidity averted for each age cohort relative to a hypothetical scenario of no historical vaccination. We then used these modelled outcomes to estimate the contribution of vaccination to globally declining infant and child mortality rates over this period. FINDINGS: Since 1974, vaccination has averted 154 million deaths, including 146 million among children younger than 5 years of whom 101 million were infants younger than 1 year. For every death averted, 66 years of full health were gained on average, translating to 10·2 billion years of full health gained. We estimate that vaccination has accounted for 40% of the observed decline in global infant mortality, 52% in the African region. In 2024, a child younger than 10 years is 40% more likely to survive to their next birthday relative to a hypothetical scenario of no historical vaccination. Increased survival probability is observed even well into late adulthood. INTERPRETATION: Since 1974 substantial gains in childhood survival have occurred in every global region. We estimate that EPI has provided the single greatest contribution to improved infant survival over the past 50 years. In the context of strengthening primary health care, our results show that equitable universal access to immunisation remains crucial to sustain health gains and continue to save future lives from preventable infectious mortality. FUNDING: WHO.

Mother, child and adolescent health outcomes in two long-term refugee camp settings at the Thai-Myanmar border 2000-2018: a retrospective analysis.

AIM: The study assessed mothers, children and adolescents' health (MCAH) outcomes in the context of a Primary Health Care (PHC) project and associated costs in two protracted long-term refugee camps, along the Thai-Myanmar border. BACKGROUND: Myanmar refugees settled in Thailand nearly 40 years ago, in a string of camps along the border, where they fully depend on external support for health and social services. Between 2000 and 2018, a single international NGO has been implementing an integrated PHC project. METHODS: This retrospective study looked at the trends of MCAH indicators of mortality and morbidity and compared them to the sustainable development goals (SDGs) indicators. A review of programme documents explored and triangulated the evolution and changing context of the PHC services, and associated project costs were analysed. To verify changes over time, interviews with 12 key informants were conducted. FINDINGS: While maternal mortality (SDG3.1) remained high at 126.5/100,000 live births, child mortality (SDG 3.2) and infectious diseases in children under 5 (SDG 3.3) fell by 69% and by up to 92%, respectively. Maternal anaemia decreased by 30%; and more than 90% of pregnant women attended four or more antenatal care visits, whereas 80% delivered by a skilled birth attendant; caesarean section rates rose but remained low at an average of 3.7%; the adolescent (15-19 years) birth rate peaked at 188 per 1000 in 2015 but declined to 89/1000 in 2018 (SDG 3.7). CONCLUSION: Comprehensive PHC delivery, with improved health provider competence in MCAH care, together with secured funding is an appropriate strategy to bring MCAH indicators to acceptable levels. However, inequities due to confinement in camps, fragmentation of specific health services, prevent fulfilment of the 2030 SDG Agenda to 'Leave no one behind'. Costs per birth was 115 EURO in 2018; however, MCAH expenditure requires further exploration over a longer period.

Early life ambient air pollution, household fuel use, and under-5 mortality in Ghana.

INTRODUCTION: Environmental exposures, such as ambient air pollution and household fuel use affect health and under-5 mortality (U5M) but there is a paucity of data in the Global South. This study examined early-life exposure to ambient particulate matter with a diameter of 2.5 µm or less (PM2.5), alongside household characteristics (including self-reported household fuel use), and their relationship with U5M in the Navrongo Health and Demographic Surveillance Site (HDSS) in northern Ghana. METHODS: We employed Satellite-based spatiotemporal models to estimate the annual average PM2.5 concentrations with the Navrongo HDSS area (1998 to 2016). Early-life exposure levels were determined by pollution estimates at birth year. Socio-demographic and household data, including cooking fuel, were gathered during routine surveillance. Cox proportional hazards models were applied to assess the link between early-life PM2.5 exposure and U5M, accounting for child, maternal, and household factors. FINDINGS: We retrospectively studied 48,352 children born between 2007 and 2017, with 1872 recorded deaths, primarily due to malaria, sepsis, and acute respiratory infection. Mean early-life PM2.5 was 39.3 µg/m3, and no significant association with U5M was observed. However, Children from households using "unclean" cooking fuels (wood, charcoal, dung, and agricultural waste) faced a 73 % higher risk of death compared to those using clean fuels (adjusted HR = 1.73; 95 % CI: 1.29, 2.33). Being born female or to mothers aged 20-34 years were linked to increased survival probabilities. INTERPRETATION: The use of "unclean" cooking fuel in the Navrongo HDSS was associated with under-5 mortality, highlighting the need to improve indoor air quality by introducing cleaner fuels.

Retrospective analysis of mortality among children under 5 years of age in Huangshi over the period 2002-2022, China.

BACKGROUND: The United Nations' Millennium Development Goals and Sustainable Development Goals both underscore the critical need to reduce the under-five mortality rate globally. China has made remarkable progress in decreasing the mortality rate of children under five. This study aims to examine the trends in child mortality rates from 2002 to 2022 and the causes of deaths among neonates, infants, and children under 5 years of age from 2013 to 2022 in Huangshi. METHODS: The data resource was supported and provided by the Huangshi Health Commission, Huangshi Maternal and Child Health Hospital, and the Huangshi Statistics Bureau. Figures were drawn using Origin 2021. RESULTS: The mortality rate among children under 5 years old significantly decreased, from 21.38 per 1,000 live births in 2002 to 3.53 per 1,000 live births in 2022. The infant mortality rate also saw a significant decline, to 15.06 per 1,000 live births. Among the 1,929 recorded child deaths from 2013 to 2022, the top three causes were: F2 (Disorders related to short gestation and low birth weight), accounting for 17.26% (333 deaths); I1 (Accidental drowning and submersion), for 14.83% (286 deaths); and I3 (Other accidental threats to breathing), for 12.29% (237 deaths). Of the 1,929 deaths, 1,117 were male children, representing 57.91%. The gender disparity in the Under-5 Mortality Rate (U5MR) was calculated to be 1.38 (boys to girls). The leading causes of death under the age of five shifted from F2 (Disorders related to short gestation and low birth weight) to I1 (Accidental drowning and submersion) as children aged, highlighting the need for policymakers and parents to intensify care and vigilance for children. CONCLUSIONS: Huangshi has achieved significant progress in lowering child mortality rates over the past two decades. The study calls for policymakers to enact more effective measures to further reduce the mortality rate among children under 5 years of age in Huangshi. Furthermore, it advises parents to dedicate more time and effort to supervising and nurturing their children, promoting a safer and healthier development.

High-risk space-time clusters of mortality in children 5 to 14 years of age in Mato Grosso state, Brazil. / Clusters Espaço-Temporais de Alto Risco da Mortalidade Infantojuvenil em Mato Grosso, Brasil.

The study aimed to detect high-risk areas for deaths of children and adolescents 5 to 14 years of age in the state of Mato Grosso, Brazil, from 2009 to 2020. This was an exploratory ecological study with municipalities as the units of analysis. Considering mortality data from the Mortality Information System (SIM) and demographic data from the Brazilian Institute of Geography and Statistics (IBGE), the study used multivariate statistics to identify space-time clusters of excess mortality risk in this age group. From 5 to 9 years of age, two clusters with high mortality risk were detected; the most likely located in the state's southern mesoregion (RR: 1.6; LRT: 8,53). Among the 5 clusters detected in the 10-14-year age group, the main cluster was in the state's northern mesoregion (RR: 2,26; LRT: 7,84). A reduction in mortality rates was observed in the younger age group and an increase in these rates in the older group. The identification of these clusters, whose analysis merits replication in other parts of Brazil, is the initial stage in the investigation of possible factors associated with morbidity and mortality in this group, still insufficiently explored, and for planning adequate interventions.

O objetivo deste estudo é detectar as áreas de maior risco para óbitos de crianças e adolescentes de 5 a 14 anos no estado de Mato Grosso entre os anos de 2009 e 2020. Estudo ecológico, tipo exploratório, cuja unidade de análise foram os municípios. Considerando dados de mortalidade do SIM e os demográficos do IBGE, o estudo utilizou a estatística multivariada para a identificação dos clusters espaço-temporais de sobrerrisco de mortalidade nesta faixa etária. Dos 5 aos 9 anos, dois clusters de alto risco de mortalidade foram detectados; o mais provável localizado na mesorregião sul (RR: 1,6; LRV: 8,53). Dentre os 5 clusters detectados na faixa etária dos 10 aos 14 anos, o principal foi localizado na mesorregião norte (RR: 2,26; LRV: 7,84). Foi identificada redução das taxas de mortalidade na faixa etária mais jovem e aumento destas taxas na faixa etária mais velha. A identificação destes clusters, cuja análise merece ser replicada a outras partes do território nacional, é a etapa inicial para a investigação de possíveis fatores associados à morbi-mortalidade deste grupo ainda pouco explorado e para o planejamento de intervenções adequadas.

Early-Neonatal, Late-Neonatal, Postneonatal, and Child Mortality Rates Across India, 1993-2021.

Importance: The global success of the child survival agenda depends on how rapidly mortality at early ages after birth declines in India, and changes need to be monitored to evaluate the status. Objective: To understand the disaggregated patterns of decrease in early-life mortality across states and union territories (UTs) of India. Design, Setting, and Participants: Repeated cross-sectional data from the 5 rounds of the National Family Health Survey conducted in 1992-1993, 1998-1999, 2005-2006, 2015-2016, and 2019-2021 were used in a representative population-based study. The study was based on data of children born in the past 5 years with complete information on date of birth and age at death. The analysis was conducted in February 2024. Exposure: Time and geographic units. Main Outcomes and Measures: Mortality rates were computed for 4 early-life periods: early-neonatal (first 7 days), late-neonatal (8-28 days), postneonatal (29 days to 11 months), and child (12-59 months). For early and late neonatal periods, the rates are expressed as deaths per 1000 live births, for postneonatal, as deaths per 1000 children aged at least 29 days and for child, deaths per 1000 children aged at least 1 year. These are collectively mentioned as deaths per 1000 for all mortalities. The relative burden of each of the age-specific mortalities to total mortality in children younger than 5 years was also computed. Results: The final analytical sample included 33 667 (1993), 29 549 (1999), 23 020 (2006), 82 294 (2016), and 64 242 (2021) children who died before their fifth birthday in the past 5 years of each survey. Mortality rates were lowest for the late-neonatal and child periods; early-neonatal was the highest in 2021. Child mortality experienced the most substantial decrease between 1993 and 2021, from 33.5 to 6.9 deaths per 1000, accompanied by a substantial reduction in interstate inequalities. While early-neonatal (from 33.5 to 20.3 deaths per 1000), late-neonatal (from 14.1 to 4.1 deaths per 1000), and postneonatal (from 31.0 to 10.8 deaths per 1000) mortality also decreased, interstate inequalities remained notable. The mortality burden shifted over time and is now concentrated during the early-neonatal (48.3% of total deaths in children younger than 5 years) and postneonatal (25.6%) periods. A stagnation or worsening for certain states and UTs was observed from 2016 to 2021 for early-neonatal, late-neonatal, and postneonatal mortality. If this pattern continues, these states and UTs will not meet the United Nations Sustainable Development Goal targets related to child survival. Conclusions and Relevance: In this repeated cross-sectional study of 5 time periods, the decrease in mortality during early-neonatal and postneonatal phases of mortality was relatively slower, with notable variations across states and UTs. The findings suggest that policies pertaining to early-neonatal and postneonatal mortalities need to be prioritized and targeting of policies and interventions needs to be context-specific.

Reducing childhood mortality extends mothers' lives.

During the twentieth century, childhood mortality was dramatically reduced globally, falling by more than 90% in the United States and much of Europe. Total fertility also fell, with the combined result that many parents who otherwise would have experienced the loss of a child were spared the trauma and negative health consequences that accompany such a loss. Here I use mathematical modeling to argue that the reduction in the frequency of child death that occurred in the twentieth century indirectly led to a substantial reduction in female mortality, resulting in an extension of female lifespan. I estimate that the reduction in maternal bereavement in the US during the twentieth century indirectly increased mean female lifespan after age 15 by approximately 1 year. I discuss implications for our understanding of the persistence of the sex gap in longevity and approaches to improving maternal health outcomes in countries that still face high levels of childhood mortality.

Can primary health care mitigate the effects of economic crises on child health in Latin America? An integrated multicountry evaluation and forecasting analysis.

BACKGROUND: Latin American and Caribbean countries are dealing with the combined challenges of pandemic-induced socicoeconomic stress and increasing public debt, potentially leading to reductions in welfare and health-care services, including primary care. We aimed to evaluate the impact of primary health-care coverage on child mortality in Latin America over the past two decades and to forecast the potential effects of primary health-care mitigation during the current economic crisis. METHODS: This multicountry study integrated retrospective impact evaluations in Brazil, Colombia, Ecuador, and Mexico from 2000 to 2019 with forecasting models covering up to 2030. We estimated the impact of coverage of primary health care on mortality rates in children younger than 5 years (hereafter referred to as under-5 mortality) across different age groups and causes of death, adjusting for all relevant demographic, socioeconomic, and health-care factors, with fixed-effects multivariable negative binomial models in 5647 municipalities with an adequate quality of vital statistics. We also performed several sensitivity and triangulation analyses. We integrated previous longitudinal datasets with validated dynamic microsimulation models and projected trends in under-5 mortality rates under alternative policy response scenarios until 2030. FINDINGS: High primary health-care coverage was associated with substantial reductions in post-neonatal mortality rates (rate ratio [RR] 0·72, 95% CI 0·71-0·74), toddler (ie, aged between 1 year and <5 years) mortality rates (0·75, 0·73-0·76), and under-5 mortality rates (0·81, 0·80-0·82), preventing 305 890 (95% CI 251 826-360 517) deaths of children younger than 5 years over the period 2000-19. High primary health-care coverage was also associated with lower under-5 mortality rates from nutritional deficiencies (RR 0·55, 95% CI 0·52-0·58), anaemia (0·64, 0·57-0·72), vaccine-preventable and vaccine-sensitive conditions (0·70, 0·68-0·72), and infectious gastroenteritis (0·78, 0·73-0·84). Considering a scenario of moderate economic crisis, a mitigation response strategy implemented in the period 2020-30 that increases primary health-care coverage could reduce the under-5 mortality rate by up to 23% (RR 0·77, 95% CI 0·72-0·84) when compared with a fiscal austerity response, and this strategy would avoid 142 285 (95% CI 120 217-164 378) child deaths by 2030 in Brazil, Colombia, Ecuador, and Mexico. INTERPRETATION: The improvement in primary health-care coverage in Brazil, Colombia, Ecuador, and Mexico over the past two decades has substantially contributed to improving child survival. Expansion of primary health-care coverage should be considered an effective strategy to mitigate the health effects of the current economic crisis and to achieve Sustainable Development Goals related to child health. FUNDING: UK Medical Research Council. TRANSLATIONS: For the Spanish and Portuguese translations of the abstract see Supplementary Materials section.

Antenatal care coverage and early childhood mortality in Zimbabwe: new interpretations from nationally representative household surveys.

Zimbabwe has implemented universal antenatal care (ANC) policies since 1980 that have significantly contributed to improvements in ANC access and early childhood mortality rates. However, Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS), two of Zimbabwe's main sources of health data and evidence, often provide seemingly different estimates of ANC coverage and under-five mortality rates. This creates confusion that can result in disparate policies and practices, with potential negative impacts on mother and child health in Zimbabwe. We conducted a comparability analysis of multiple DHS and MICS datasets to enhance the understanding of point estimates, temporal changes, rural-urban differences and reliability of estimates of ANC coverage and neonatal, infant and under-five mortality rates (NMR, IMR and U5MR, separately) from 2009 to 2019 in Zimbabwe. Our two samples z-tests revealed that both DHS and MICS indicated significant increases in ANC coverage and declines in IMR and U5MR but only from 2009 to 2015. NMR neither increased nor declined from 2009 to 2019. Rural-urban differences were significant for ANC coverage (2009-15 only) but not for NMR, IMR and U5MR. We found that there is a need for more precise DHS and MICS estimates of urban ANC coverage and all estimates of NMR, IMR and U5MR, and that shorter recall periods provide more reliable estimates of ANC coverage in Zimbabwe. Our findings represent new interpretations and clearer insights into progress and gaps around ANC coverage and under-five mortality rates that can inform the development, implementation, monitoring and evaluation of policy and practice responses and further research in Zimbabwe.