Age Distribution, Trends, and Forecasts of Under-5 Mortality in Sub-Saharan Africa

AbstractBackgroundDespite the sharp decline in global under-5 deaths since 1990, uneven progress has been achieved across and within countries. In Sub-Saharan Africa, the Millennium Development Goals targets for child mortality were met only by a few countries, and recently new targets were set in goals for Sustainable Development that include the eradication of preventable deaths by reducing neonatal and under-5 mortality rates to at least as low 12 and 25 per 1000 live births by 2030, respectively. As the reduction of preventable deaths has a direct impact on their age distribution, the foci of this study are assessing age patterns, trends over time, and forecasts of mortality rates in Sub-Saharan Africa.Methods and findingsData came from 104 nationally-representative Demographic and Health Surveys with full birth histories from 31 Sub-Saharan African countries from 1990 to 2016 (a total of 448 country-years of data). We assessed the distribution of age at death through the following demographic model. First, we used a direct method for the estimation of death rates with full-birth histories from survey data to construct age profiles of under-5 mortality on a monthly basis. Second, a two-dimensional P-spline approach was used to smooth out raw estimates of death rates by age and time. Third, a variant of the Lee-Carter model, designed for populations with limited data, was used to fit and forecast age profiles of mortality. We used mortality estimates from the United Nations Inter-agency group for Child Mortality Estimation to adjust, validate and minimize the risk of bias in survival, truncation, and recall in mortality estimation.Our study has three salient findings. First, we observe a monotonous decline of death rates at every age in most countries, but with notable differences in the age-patterns over time. Second, our projections of continued decline of child mortality differ from existing estimates from the United Nations Inter-agency group for Child Mortality Estimation in 5 countries for both neonatal and under-5 mortality. Finally, we predict that only 5 countries (Guinea, Liberia, Rwanda, Tanzania, and Uganda) are on track to achieve the sustainable development goal targets on child mortality by 2030. Poor data quality issues that include bias in the report of births and deaths, or age heaping, remain a limitation of this study.ConclusionsThis study is the first to combine full birth history data and mortality estimates from external reliable sources to model age patterns of under-5 mortality across time in Sub-Saharan Africa. We demonstrate that countries with a rapid pace of mortality reduction across ages would be more likely to achieve the sustainable development goal targets of child mortality reduction. Our mortality model predicts that if neonatal and under-5 deaths decline at the rates observed during the last 25 years, only 5 countries would reach those targets by 2030, 15 would achieve them between 2030 and 2050, and 11 afterwards.