Articles

Global, regional, and national levels and trends in under-5

mortality between 1990 and 2015, with scenario-based
projections to 2030: a systematic analysis by the UN
Inter-agency Group for Child Mortality Estimation
Danzhen You, Lucia Hug, Simon Ejdemyr, Priscila Idele, Daniel Hogan, Colin Mathers, Patrick Gerland, Jin Rou New, Leontine Alkema, for the
United Nations Inter-agency Group for Child Mortality Estimation (UN IGME)

Summary
Background In 2000, world leaders agreed on the Millennium Development Goals (MDGs). MDG 4 called for a
two-thirds reduction in the under-5 mortality rate between 1990 and 2015. We aimed to estimate levels and trends in
under-5 mortality for 195 countries from 1990 to 2015 to assess MDG 4 achievement and then intended to project how
various post-2015 targets and observed rates of change will aect the burden of under-5 deaths from 2016 to 2030.
Methods We updated the UN Inter-agency Group for Child Mortality Estimation (UN IGME) database with
5700 country-year datapoints. As of July, 2015, the database contains about 17 000 country-year datapoints for mortality
of children younger than 5 years for 195 countries, and includes all available nationally-representative data from vital
registration systems, population censuses, household surveys, and sample registration systems. We used these data
to generate estimates, with uncertainty intervals, of under-5 (age 04 years) mortality using a Bayesian B-spline biasreduction model (B3 model). This model includes a data model to adjust for systematic biases associated with
dierent types of data sources. To provide insights into the global and regional burden of under-5 deaths associated
with post-2015 targets, we constructed ve scenario-based projections for under-5 mortality from 2016 to 2030 and
estimated national, regional, and global under-5 mortality rates up to 2030 for each scenario.
Results The global under-5 mortality rate has fallen from 906 deaths per 1000 livebirths (90% uncertainty interval
893922) in 1990 to 425 (409456) in 2015. During the same period, the annual number of under-5 deaths
worldwide dropped from 127 million (126 million130 million) to 59 million (57 million64 million). The
global under-5 mortality rate reduced by 53% (5055%) in the past 25 years and therefore missed the MDG 4 target.
Based on point estimates, two regionseast Asia and the Pacic, and Latin America and the Caribbeanachieved
the MDG 4 target. 62 countries achieved the MDG 4 target, of which 24 were low-income and lower-middle income
countries. Between 2016 and 2030, 944 million children are projected to die before the age of 5 years if the 2015
mortality rate remains constant in each country, and 688 million would die if each country continues to reduce its
mortality rate at the pace estimated from 2000 to 2015. If all countries achieve the Sustainable Development Goal of
an under-5 mortality rate of 25 or fewer deaths per 1000 livebirths by 2030, we project 560 million deaths by 2030.
About two-thirds of all sub-Saharan African countries need to accelerate progress to achieve this target.

Published Online
September 9, 2015
http://dx.doi.org/10.1016/
S0140-6736(15)00120-8
See Online/Comment
http://dx.doi.org/10.1016/
S0140-6736(15)00193-2
Division of Data, Research, and
Policy, UNICEF, New York, NY,
USA (D You PhD, L Hug MA,
S Ejdemyr MA, P Idele PhD);
WHO, Geneva, Switzerland
(D Hogan PhD, C Mathers PhD);
United Nations Population
Division, New York, NY, USA
(P Gerland PhD); University of
California, Berkeley, CA, USA
(J R New MA); and Department
of Biostatistics and
Epidemiology, School of Public
Health and Health Sciences,
University of Massachusetts,
Amherst, MA, USA
(L Alkema PhD)
Correspondence to:
Dr Danzhen You, Division of
Data, Research, and Policy,
UNICEF, New York,
NY 10017, USA
dyou@unicef.org

Interpretation Despite substantial progress in reducing child mortality, concerted eorts remain necessary to avoid
preventable under-5 deaths in the coming years and to accelerate progress in improving child survival further. Urgent
actions are needed most in the regions and countries with high under-5 mortality rates, particularly those in
sub-Saharan Africa and south Asia.
Funding None.
Copyright 2015. World Health Organization. Published by Elsevier Ltd/Inc/BV. All rights reserved.

Introduction
The year 2015 is crucial for policy discussions about
child survival, not only because it is the target year for
nal reporting on the Millennium Development Goals
(MDGs), but also because it is the year in which
stakeholders are coming together to agree on the
post-2015 agenda. In 2000, world leaders agreed on the
MDGs and called for a two-thirds reduction in the
under-5 mortality rate (U5MR) between 1990 and

2015known as the MDG 4 target.1 In recent years,

global momentum and investment to accelerate gains in
child survival have increased. During the UN MDG
Summit in September, 2010, UN Secretary-General Ban
Ki-moon launched Every Woman Every Child,2 an
unprecedented global movement to mobilise and
intensify international and national action by
governments, international agencies, non-governmental
organisations, the private sector, and civil society to

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Articles

Research in context
Evidence before this study
Nationally representative high-quality data for mortality of
children younger than 5 years are available at regular time
intervals from vital registration for only about 60 countries.
For the rest of the world, knowledge depends on data from
population censuses, household surveys, and sample
registration systems. All publicly available data for under-5,
infant, and neonatal mortality are compiled annually by the UN
Inter-agency Group for Child Mortality Estimation (UN IGME) to
improve monitoring of progress towards child survival goals
and to enhance the capacity of countries to produce timely
estimates of child mortality. The UN IGME global database
before this study contained about 16 000 observations with
meta-information from 1950 (or earlier) to 2013 available as of
July, 2014. The UN IGME uses this information to produce
annual updates, typically released in September, of neonatal,
infant, and under-5 mortality rates and trends for 195 countries
or areas.
Added value of this study
This study provides estimates of under-5 mortality up to the
Millennium Development Goal (MDG) target year (2015) and
constructs scenario-based projections from 2016 to 2030 to
provide insights into the burden of under-5 deaths in the next
15 years. This study extended the existing UN IGME global
database by including 5700 new or updated observations and
also incorporated updated HIV/AIDS estimates from UNAIDS
and revised population numbers from the UN Population

address the major health challenges facing women and

children around the world. In June, 2012, world leaders
renewed their commitment during the global launch of
Committing to Child Survival: A Promise Renewed (APR),3
aiming for a continued post-2015 focus to end
preventable child deaths, and with a target U5MR of 25
or fewer deaths per 1000 livebirths by 2030 or 20 or fewer
deaths per 1000 livebirths by 2035 for all countries. The
international community is in the process of agreeing
on a new framework, known as the Sustainable
Development Goals (SDGs), that will guide and motivate
future global and national action. They seek to build
upon the foundation laid by the MDGs, not only
completing unnished business but also working
towards setting ambitious new goals that will constitute
an integrated and indivisible set of global priorities for
sustainable development.4 Ending preventable deaths of
newborn babies and children younger than 5 years by
2030, with all countries aiming to reduce neonatal
mortality to at least as low as 12 deaths per 1000 livebirths
and under-5 mortality to at least as low as 25 deaths per
1000 livebirths, has been proposed as an SDG target
under goal 3, which seeks to ensure healthy lives and
promote wellbeing at all ages.5
Data-driven estimates for child mortality are necessary
to track progress towards child survival goals and to
2

Division. On the basis of this empirical database and updated

demographic inputs, we constructed country-specic under-5
mortality rate estimates for 195 countries from 1990 (or
earlier) to 2015 to assess levels and trends in child mortality and
to monitor progress in child survival. These estimates were
constructed with the Bayesian B-spline bias-reduction model to
produce estimates of mortality rates and associated indicators,
such as rates of change and aggregate outcomes, with 90%
uncertainty intervals.
Implications of all the available evidence
Although great progress in reducing child mortality has been
made since 1990 (more than two-thirds of 195 countries have
at least halved their under-5 mortality rate from 1990 to 2015)
progress has been insucient worldwide to achieve MDG 4,
which requires a two-thirds reduction in the under-5 mortality
rate. Without any acceleration in the pace of reduction in child
mortality as compared with country-specic rates of decline in
200015, 688 million children will die before they reach their
fth birthday in 201630. The more ambitious aim of an
under-5 mortality rate of 25 or fewer deaths per 1000 livebirths
for all countries by 2030 would correspond to substantially
fewer deaths in the next 15 years, but requires concerted eorts
to enable continued improvements in child survival in countries
that have had recent accelerations and moreover, immediate
action to accelerate child survival improvements for countries
with little progress in the last decades.

plan national and global health strategies, policies, and

interventions for child health.6,7 As opposed to adult or
old-age mortality, child mortality is the one indicator that
is based on a comparably large amount of empirical data
in low-income and middle-income countries,8 which
makes it unique from a monitoring perspective.
However, the estimation of child mortality is still
challenging for the great majority of developing countries
without well functioning civil registration systems due to
data quality issues. Modelling exercises are usually
required to generate reliable and comparable child
mortality estimates. With increasing implementation of
evidence-based interventions to reduce child mortality,
demand is increasing for frequent, accurate, and
transparent monitoring.
Many studies have shown that remarkable progress has
been made since 1990 to improve child survival but that
progress has been insucient to achieve MDG 4.915 In the
concluding year of the MDGs, it is time to take stock of
what has been achieved in improving child survival, and
to share success stories and learn lessons from failures. It
is also essential to look beyond the MDGs to the post-2015
SDGs to identify potential challenges in ending
preventable deaths of children younger than 5 years.
In this Article, we estimate levels and trends for child
mortality and provide an overview of global, regional,

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Articles

and country-specic progress towards MDG 4. We also

present projections of U5MR and the associated numbers
of deaths up to 2030 under ve scenarios to provide
insight into the post-2015 burden of under-5 deaths.

Methods
Estimation of under-5 mortality
The UN Inter-agency Group for Child Mortality Estimation
(UN IGME) was established in 2004 to improve
monitoring of progress towards child survival goals and to
enhance the capacity of countries to produce timely
estimates of child mortality. It is led by the UN Childrens
Fund (UNICEF), and includes WHO, UN Population
Division, and World Bank. The group is advised by an
independent technical advisory group of leading experts
in demography and biostatistics. The UN IGME produces
annual updates, usually released in September, of
neonatal, infant, and under-5 mortality levels and trends
for 195 countries or areas. These UN IGME estimates
represent the most up-to-date comprehensive information
on child mortality and provide a basis for assessing
progress and reaching consensus for action.16
The UN IGME estimation process aims to compile all
available nationally-representative empirical data relevant
to child mortality, which includes to access various data
sources, assess data quality, recalculate harmonised data
inputs, and make adjustments, if needed, through
standard methods, and then to t statistical models to
these data to generate smoothed time series and
uncertainty ranges and extrapolate to a target year.10
Below we summarise our database and analysis
approach; details about data sources and methods used
to generate mortality rates and number of deaths are
available online (appendix pp 211).
Nationally-representative data of under-5 mortality
can be derived from several dierent sources, including
civil registration, censuses, and sample surveys.
Demographic surveillance sites and hospital data are
excluded because they are rarely nationally representative. The preferred source of data is a civil
registration system that records births and deaths on a
continuous basis. If registration is complete and the
system functions eciently, then the resulting estimates
will be accurate and timely. However, most low-income
and middle-income countries do not have well
functioning civil registration systems, and household
surveys and periodic population censuses have become
the primary source of data for child mortality. However,
these data often have (sometimes substantial) sampling
or non-sampling errors.15
The UN IGME web portal hosts the full set of empirical
data. The 2015 update to the UN IGME database included
more than 5700 new or updated country-year datapoints
for U5MR from more than 130 series. The database, as of
July, 2015, contains 17 000 country-year datapoints from
more than 1500 series across 195 countries from 1990
(or earlier) to 2015.

We estimated U5MR (the probability of dying before

age 5 years) using the Bayesian B-spline bias-reduction
model, referred to as the B3 model.17 This model was
developed, validated, and used to produce previous
rounds of the UN IGME child mortality estimates
published in 201314 and 2014.15 In the B3 model,
log(U5MR) is estimated with a exible spline regression
model (appendix pp 211). We tted the spline regression
model to all U5MR observations (ie, country-year
datapoints) in the country. An observed value for U5MR
is considered to be the true value for U5MR multiplied
by an error factorie, observed U5MR = true
U5MR*error, or on the log-scale, log(observed
U5MR) = log(true U5MR) + log(error), in which error
refers to the relative dierence between an observation
and the true value. While estimating the true U5MR,
properties of the errors that provide information about
the quality of the observation, or in other words, the
extent of error that we expect, are taken into account.
These properties include: the standard error of the
observation (due to sampling) or its stochastic error (for
vital registration data to capture the uncertainty in
outcomes of random events), the type of data source (eg,
Demographic and Health Survey vs census), the type of
data collection method (eg, full or summary birth
histories), the dierence between the observation
reference date and the survey time, and if the observation
is part of a specic data series (and how consistent the
data series is with other series with overlapping
observation periods). These properties are summarised
in the so-called data model (appendix pp 68 and
Alkema and New17). When estimating the U5MR, the
data model accounts for the errors in empirical data
(including the average systematic biases associated with
dierent types of data sources), using information on
data quality for dierent types of data sources from all
countries in the world.
For countries with high-quality vital registration data, a
variation of the B3 model is used to obtain the infant
mortality rate (IMR; the probability of dying before age
1 year), whereby estimates are constructed for the logit
transform of rie, log(r/1r), where r is the ratio of the
IMR to the median B3 estimates of U5MR in the
corresponding country-year. The transform is used to
restrict the IMR to be lower than the U5MR. For
the remaining countries without high-quality vital
registration data, the IMR is derived from the U5MR
through the use of model lifetables that contain known
regularities in age patterns of child mortality.10
Given the inherent uncertainty in child mortality
estimates, 90% uncertainty intervals (90% UIs) are used
by the UN IGME instead of the more conventional 95%
intervals. Although reporting intervals that are based on
higher levels of uncertainty (ie, 95% instead of 90%)
would reduce the chance of not including the true value
in the interval, the disadvantage of choosing higher
uncertainty levels is that intervals lose their use to

www.thelancet.com Published online September 9, 2015 http://dx.doi.org/10.1016/S0140-6736(15)00120-8

See Online for appendix

For UN IGME web portal see

http://childmortality.org/
For a spreadsheet of the
underlying data see
http://bit.ly/1Fsu9un

Articles

Panel: The ve projection scenarios

In all scenarios, if a country reaches the current lowest U5MR observed among countries
with more than 10 000 livebirths (23 deaths per 1000 livebirths in Finland), its U5MR will
remain at that level for the remainder of the projection period. For countries with 10 000
livebirths or fewer that had a U5MR lower than 23 per 1000 livebirths in 2015 (Iceland
and Luxembourg), the U5MR will remain at its current level for the projected years.
Scenario one: no change from 2015 mortality rate
For each country, the U5MR for 201530 is kept the same as the U5MR estimated for 2015.
Scenario two: current trends
For each country, the ARR for 201530 is equal to the estimated country-specic ARR
from 2000 to 2015. If a country has a negative ARR in 200015 (ie, an increase in
mortality rates in 200015), projections from scenario one are used (constant U5MR).
Scenario three: best regional performer
For each country, the ARR for 201530 is equal to the ARR from the best performing
country in its respective region (with the highest ARR) for 200015. The top regional
performers in 200015 were Belarus (CEE/CIS), Cambodia (east Asia and the Pacic),
Estonia (other countries), Lebanon (Middle East and north Africa), Maldives (south Asia),
Peru (Latin America and the Caribbean), Rwanda (eastern and southern Africa), and
Senegal (west and central Africa).
Scenario four: SDG target
For each country, the U5MR in 2030 is equal to 25 deaths per 1000 livebirths and ARRs
for 201530 are calculated on the basis of the countrys mortality level in 2015 and the
SDG target. For countries that have already reached the target or are on track to reach
the target before 2030 according to scenario two, projections from scenario two
are used.
Scenario ve: average mortality rate of high-income countries by 2030
Same projection strategy as in scenario four, except that the 2030 U5MR target is 68 deaths
per 1000 livebirthsthe average mortality rate in high-income countries as of 2015.
U5MR=under-5 mortality rate. ARR=annual rate of reduction. CEE/CIS=central and eastern Europe and the Commonwealth of
Independent States. SDG=Sustainable Development Goal. For regional classication, see appendix pp 1214.

present meaningful summaries of a range of likely

outcomes when the indicator of interest is highly
uncertain. Given this trade-o and the substantial
uncertainty associated with child mortality estimates, the
UN IGME chose to report 90% UIs, or, in other words,
intervals for which there is a 90% chance that they
contain the true value, to encourage wider use and
interpretation of the UIs.
The number of estimated deaths was calculated using
lifetable approaches,18 based on the estimated mortality
rates, as well as estimates of population numbers by the
UN Population Division.19 All results are presented with
90% UIs, which are constructed from the posterior
samples of U5MR by excluding 5% of the smallest and
5% of the largest samples. The resulting UIs are not
necessarily symmetrical around the point estimates, but
reect the uncertainty range associated with the mortality
rates. The UIs for the number of deaths generated by the
UN IGME do not account for uncertainty associated with
other inputs to its calculation, such as the population
under the age of 5 years, because uncertainty assessments
4

of these inputs are not yet available. The B3 model codes

are available from the UN IGME on request.
In this round of estimation, the UN IGME generated
mortality estimates for 195 countries from 1990 (or
earlier) to 2015, depending on availability of empirical
data for each country. Estimates are available for all
countries from 1990 onwards and for 141 countries from
1970 onwards. Of the 54 countries for which estimates
from 1970 are not available, 30 either have small
populations or were founded in later years. The
141 countries with available estimates in 1970 account for
94% of the global under-5 population. To construct
aggregate estimates of number of deaths from 1970
onwards, regional averages of mortality rates were used
for country-years with missing information. If a country
was established after 1990, we still generated estimates of
U5MR in the country starting in 1990. For the years
before establishment, we recalculated U5MR from
empirical data for the territory that subsequently became
a country if datasets were available. We then tted the B3
model to these empirical data to derive trend estimates
for the country from 1990.

Scenarios for projections to 2030

We considered ve dierent scenarios (panel) under
which we project annual U5MR and number of deaths
from 2016 to 2030. Projections are based on either the
U5MR level for future years or the annual rate of
reduction (ARR) in the U5MR, which is dened as
ARR=log(U5MRt/U5MRt) / (t t) where t and t refer
to dierent years with t<t.
We calculated the number of projected deaths using
lifetable approaches,18 based on our projected mortality
rates and estimates of projected population numbers by
the UN Population Division from 2016 to 2030.19 The
population numbers used to calculate the number of
deaths are the same for each scenario. By comparing the
numbers of deaths among dierent scenarios, the
number of lives saved due to a faster mortality decline
can be calculated. Changes in child mortality might
result in some changes in child population. These
changes were not taken into account in our projections to
allow simple comparisons. Thus, the scenarios do not
reect the real number of lives saved, but rather the
potential number of lives that would have been saved due
to mortality declines if the child population in each
country remains xed at the median population numbers
projected by the UN Population Division. Moreover, the
projections relied on historical trends in mortality or
were based on the ARR required to achieve specic
targets in 2030. They did not take into account potential
changes in intervention coverage and other factors
associated with child mortality reduction.

Role of the funding source

There was no funding source for this study. The
corresponding author had full access to all the data in the

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Articles

Under-5 mortality rate (deaths per 1000 livebirths)

Number of under-5 deaths (millions)

1970

1990

2015

Decrease 1990
to 2015 (%)

1970

1990

2015

Decrease 1990
to 2015 (%)

1449
(14061500)

906
(893922)

425
(409456)

53%
(5055)

172
(167179)

127
(126130)

59
(5764)

53%
(5055)

Africa

2404
(23352497)

1641
(16111676)

763
(713851)

54%
(4857)

38
(3740)

42
(4142)

31
(2934)

26%
(1731)

52%
(4955)

Sub-Saharan Africa

2443
(23592557)

1802
(17681842)

831
(775930)

54%
(4857)

32
(3033)

39
(3840)

29
(2733)

24%
(1429)

50%
(4753)

Eastern and southern Africa

2127
(20112267)

1665
(16241714)

665
(604781)

60%
(5364)

13
(1314)

17
(1718)

11
(1013)

39%
(2844)

18%
(1621)

West and central Africa

2755
(26232927)

1984
(19252049)

987
(8821138)

50%
(4356)

17
(1618)

20
(2021)

18
(1621)

12%
(222)

30%
(2733)

Middle East and north Africa

1995
(19342066)

710
(694730)

289
(266321)

59%
(5563)

12
(1213)

07
(0607)

03
(0304)

51%
(4555)

5%
(56)

Asia

1537
(14691615)

903
(882927)

364
(339395)

60%
(5663)

109
(103115)

72
(7074)

24
(2226)

67%
(6469)

41%
(3743)

South Asia

2132
(20592212)

1293
(12611326)

525
(480578)

59%
(5563)

58
(5661)

47
(4648)

19
(1721)

60%
(5664)

31%
(2934)

East Asia and the Pacic

1164
(10571283)

583
(554618)

178
(164197)

69%
(6672)

50
(4555)

25
(2427)

05
(0506)

79%
(7681)

9%
(810)

Latin America and the Caribbean

1196
(11631234)

538
(522557)

179
(171193)

67%
(6469)

12
(1213)

06
(0607)

02
(0202)

69%
(6671)

3%
(34)

CEE/CIS

966
(9071035)

476
(462491)

171
(148220)

64%
(5469)

06
(0607)

04
(0304)

01
(0101)

69%
(6074)

2%
(22)

Other countries

245
(243246)

104
(103105)

48
(4553)

54%
(4957)

03
(0303)

01
(0101)

01
(0001)

56%
(5260)

1%
(11)

Low income

2566
(24642695)

1872
(18351916)

761
(711852)

59%
(5562)

23
(2224)

26
(2526)

17
(1619)

35%
(2739)

28%
(2631)

Lower middle income

2002
(19542060)

1195
(11741218)

528
(493577)

56%
(5259)

90
(8893)

72
(7173)

35
(3338)

51%
(4755)

59%
(5661)

Upper middle income

1171
(10701285)

554
(528584)

191
(170228)

66%
(5970)

55
(5061)

27
(2629)

07
(0608)

75%
(7078)

11%
(1013)

High income

324
(313337)

156
(153159)

68
(6475)

56%
(5259)

06
(0506)

03
(0303)

01
(0101)

59%
(5561)

2%
(22)

World

Share of total
deaths
worldwide in
2015 (%)

By region

By income group

For regional classication, including a list of countries in Other countries, see appendix pp 1213. Income group classication is from the World Bank (appendix pp 1314). CEE/CIS=central and eastern Europe
and Commonwealth of Independent States.

Table 1: Global and regional under-5 mortality rates and number of under-5 deaths, with 90% uncertainty intervals

study and had nal responsibility for the decision to

submit for publication.

Results
In 2015, the global U5MR is 425 (90% UI 409456)
deaths per 1000 livebirths and the estimated
number of under-5 deaths is 59 million (90% UI
57 million64 million; table 1). In total, an estimated
2363 million (2337 million2402 million) children died
before their fth birthday between 1990 and 2015.
Wide disparities in mortality rates exist across regions
(gure 1). West and central Africa continues to have the
highest U5MR worldwide with a U5MR of 987
(90% UI 8821138) deaths per 1000 livebirths, almost
15 times higher than the average U5MR in high-income

countries (68 deaths per 1000 livebirths). This region

also accounts for a large share of the total number of
under-5 deaths in the worldie, 18 million deaths
(16 million21 million; 30% of worldwide deaths)
occurred in west and central Africa alone. Another
19 million (17 million21 million; 31%) of the deaths
occurred
in
south
Asia
and
11
million
(10 million13 million; 18%) in eastern and southern
Africa. At the country level, U5MR ranged from
1569 (9482537) deaths per 1000 livebirths in Angola
to 19 (1326) in Luxembourg in 2015 (gure 2;
appendix pp 1523). All seven countries with a U5MR of
more than 100 deaths per 1000 livebirths are in subSaharan Africa: Angola, Chad, Somalia, Central African
Republic, Sierra Leone, Mali, and Nigeria.

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Articles

Under-5 mortality rate (deaths per 1000 livebirths)

West and
central Africa

Eastern and
southern Africa

South Asia

Middle East and

north Africa

East Asia
and the Pacific

CEE/CIS

Latin America and

the Caribbean

Other
countries

200

150

100

50

Under-5 deaths (millions)

19
9
19 0
9
20 5
0
20 0
0
20 5
1
20 0
15
19
9
19 0
9
20 5
0
20 0
0
20 5
1
20 0
15
19
9
19 0
9
20 5
0
20 0
0
20 5
1
20 0
15
19
9
19 0
9
20 5
0
20 0
0
20 5
1
20 0
15
19
9
19 0
9
20 5
0
20 0
0
20 5
1
20 0
15
19
9
19 0
9
20 5
00
20
0
20 5
1
20 0
15
19
9
19 0
9
20 5
00
20
0
20 5
1
20 0
15
19
9
19 0
9
20 5
00
20
0
20 5
1
20 0
15

0
Year

Year

Year

Year

Year

Year

Year

Year

Figure 1: Trends in the under-5 mortality rate and number of under-5 deaths, with 90% uncertainty intervals, by region
CEE/CIS=central and eastern Europe/Commonwealth of Independent States. See appendix pp 1213 for regional classication, including for those included in Other countries.

Under-5 mortality rate, 2015

(deaths per 1000 livebirths)
>100
75100
5075
2550
25
No data

For an interactive map with

these data see
http://bit.ly/1EISCRf

Figure 2: Under-5 mortality rate in 2015 by country

This map does not reect a position by UN IGME agencies or those of the institutions to which the authors are aliated on the legal status of any country or territory.
The dotted line represents approximately the Line of Control in Jammu and Kashmir agreed upon by India and Pakistan. The nal status of Jammu and Kashmir has
not yet been agreed upon by the parties. The nal boundary between the Sudan and South Sudan has not yet been determined. The nal status of the Abyei area has
not yet been determined. An interactive map with these data is available online.

Substantial progress was made in reducing child

mortality in the last four decades, with the global U5MR
falling from 1449 deaths per 1000 livebirths in 1970 to

425 in 2015 (table 1, gure 1). During the MDG period

from 1990 to 2015, U5MR reduced by 53% (90% UI
5055%) worldwide, and therefore missed the MDG 4

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Articles

A
ARR in under-5 mortality (%)

Eastern and southern Africa

World

100

West and central Africa

75

B
197090

19902000

200015

World

50
Eastern and
southern

25

Africa
0
West and
central

25

Africa
Middle East and north Africa

100

East Asia and the Pacic

South Asia

ARR in under-5 mortality (%)

Middle East
and north

75

Africa
50
East Asia
and the Pacic

25
0

South Asia

25

ARR in under-5 mortality (%)

100

Latin America
Latin America and the Caribbean

CEE/CIS

and the

Other countries

Caribbean

75

CEE/CIS

50

Other
countries

25
0

Year

Year

20
10

20
00

80

19
90

19

70
19

20
10

20
00

80

70

19
90

19

19

20
10

20
00

80

19
90

19

19

70

25
Year

Average ARR (90% UI)

Figure 3: Annual (A) and average (B) ARR in under-5 mortality rate (90% UI), worldwide and by region
The vertical dotted lines at 1990 represent the starting year of the Millennium Development Goals period. Note that spikes in ARR are due to crisis mortality: the ARR
for Latin America and the Caribbean in 2010 is aected by the earthquake in Haiti. The ARR in east Asia and the Pacic is aected by the southeast Asian tsunami in
2004 and the Myanmar cyclone in 2008. The ARR in eastern and southern Africa around 1994 is aected by the Rwanda genocide. Regional estimates CEE/CIS are
not presented before 1980 due to lack of underlying data in countries in the region. Regional classication can be found on pp 1214 of the appendix. ARR=annual
rate of reduction. CEE/CIS=central and eastern Europe/Commonwealth of Independent States.

target of a two-thirds reduction. All regions in the world,

based on the point estimates, have registered at least a
50% reduction in the U5MR since 1990 (table 1).
Two regionseast Asia and the Pacic (69% reduction)
and Latin America and the Caribbean (67% reduction)
achieved the MDG 4 target (table 1).
At the country level, 62 (32%) of 195 countries for
which UN IGME produces estimates achieved the
MDG 4 target based on point estimates. Among them,
12 are low-income countries (Cambodia, Ethiopia,
Eritrea, Liberia, Madagascar, Malawi, Mozambique,
Nepal, Niger, Rwanda, Uganda, and Tanzania) and
another 12 are lower-middle-income countries
(Armenia, Bangladesh, Bhutan, Bolivia, Egypt,
El Salvador, Georgia, Indonesia, Kyrgyzstan, Nicaragua,
Timor-Leste, and Yemen). An additional 74 countries

reduced their U5MR by at least 50%, and another

41 countries by at least 30%. For a country to meet the
MDG 4 target, the ARR in the U5MR between 1990 and
2015 needs to reach 44% or higher (equivalent to a twothirds reduction in 25 years). Online (appendix pp 1523
and pp 7273) we provide detailed country information
on the ARRs, including point estimates (which are used
to assess the MDG 4 achievement) as well as 90% UIs of
the ARRs, and the probability that a country achieved
the MDG 4 target, which is the percentage of posterior
samples with an ARR of 44% or higher. The UIs and
probabilities quantify the uncertainty associated with
the assessment related to MDG 4 achievements. This
information allows for pinpointing countries that we
are very certain about achievements in reductions in
under-5 mortality.

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Articles

Under-5 mortality rate (deaths per 1000 livebirths)

Reductions in under-5 mortality have accelerated

worldwide since 1990 (gure 3). The global U5MR
dropped at an ARR of between 2% and 3% from 1970 to
the early 1980s, but slowed during the 1980s and early
1990s. Slower progress in populous countries including
China and Nigeria in the 1980s contributed to the decline
in the global ARR in the 1980s. The acceleration in
increases in child survival in China from around 1990, in
50

472
425

40

30

262

20

172
132

10

61

0
66

Under-5 deaths (millions)

59

36

24
18
08

0
2015

2020

2025
Year
Scenario 1: no change from 2015 mortality rate
Scenario 2: current trends
Scenario 3: best regional performer
Scenario 4: SDG target
Scenario 5: average mortality rate of HIC by 2030

2030

Figure 4: Projected global under-5 mortality rate and the number of under-5
deaths under various scenarios, 201530
SDG=sustainable development goals. HIC=high-income country.

Nigeria since the mid-1990s, and in India from around

2000 contributed to the increasing global ARR since the
early 1990s. The world reached an ARR of about 4% in
the early 2000s and remained at that level for a decade.
After 2010, the ARR is more uncertain for the world as
well as for many regions. This is due to scarcity of
empirical data in recent years. South Asia is the only
region in which continued acceleration has occurred
since 1970. Seven of the eight regions reached an ARR of
more than 3% in 200015 (gure 3B).
At the country level, 102 (52%) of the 195 countries had
a faster decline in 200015 than in 19902000 based on
point estimates of the ARRs (appendix pp 1523). Of the
49 sub-Saharan African countries, all but ve (90%) had a
higher ARR in the 200015 period than in the 1990s.
Among these 49 countries, 21 (43%) countries reversed
an increasing U5MR trend in 200015 compared with
the 1990s or had an ARR over the past 15 years that is at
least triple the rate that they achieved in the 1990s:
Angola, Botswana, Burkina Faso, Burundi, Cameroon,
Central African Republic, Congo (Brazzaville), Cte
dIvoire, Gabon, Kenya, Lesotho, Mauritania, Namibia,
Rwanda, Senegal, Sierra Leone, Somalia, South Africa,
Swaziland, Zambia, and Zimbabwe. Many of these
countries had a rise in U5MR in the 1990s due to HIV
and AIDS, but then reversed U5MR trends around 2000,
partly because of eorts in HIV prevention and
treatment. The estimates indicate that the accelerated
progress globally since 2000 has saved about 18 million
childrenthat is, 18 million children would not have
survived to see their fth birthday had the U5MR
declined at the pace recorded in the 1990s.
Figure 4 and table 2 show the scenario-based
projections of U5MR and the number of under-5 deaths
in the world from 2015 to 2030. Under scenario one (no
change from 2015 mortality rate), the global U5MR
would be 472 deaths per 1000 livebirths and the number
of deaths would be 66 million in 2030both higher
than the 2015 numbers. This rise is due to the growing
number of births and under-5 population and a shift of
the share of the population towards sub-Saharan Africa,
particularly west and central Africa, within which the

Projected under-5 mortality rate

(deaths per 1000 livebirths)

Projected under-5 deaths

(millions)

Projected total
number of
deaths
(millions)

2020

2025

2030

2020

2025

2030

Scenario 1: No change from 2015 mortality rate

442

458

472

62

64

66

201630
944

Scenario 2: Current trends

362

308

262

50

42

36

688

Scenario 3: Best regional performer

285

194

132

39

26

18

494

Scenario 4: SDG target

313

232

172

43

32

24

560

Scenario 5: Average mortality rate of HIC by 2030

216

113

61

30

15

08

354

SDG=sustainable development goal. HIC=high-income country.

Table 2: Projected global under-5 mortality rate and under-5 deaths under dierent scenarios

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Articles

Discussion
Remarkable progress has been made worldwide to
improve child survival over the past 25 years. The global
U5MR declined by 53% and the number of under-5 deaths
dropped from 127 million in 1990 to 59 million in 2015.
All regions have reduced their U5MR at least by half and
progress has accelerated worldwide: the global ARR has
steadily doubled. In sub-Saharan Africa (the region with
the highest U5MR in the world) the ARR increased from
16% in the 1990s to 41% in 200015. The recent trend is
especially encouraging in eastern and southern Africa,
which had an average ARR of almost 5% in 200015.

Low-income country
Lower-middle-income country
Upper-middle-income country
High-income country

Angola
12
Chad

Somalia

Central African Republic

Required ARR from 2015, to reach an
under-5 mortality rate of 25 deaths per 1000 livebirths in 2030

highest regional U5MR persists. Under scenario one,

944 million children would die in 201630.
If all countries continue their current trends (ie, their
average ARR in 200015; scenario two), the global U5MR
would be 262 deaths per 1000 livebirths in 2030, down
from 425 in 2015 (a 38% reduction over 15 years). This
would result in 688 million under-5 deaths over the next
15 years, with 36 million of them in the year 2030
substantial progress compared with scenario one.
Under scenario three (best regional performer
scenario), if every country instead obtained the highest
ARR achieved by the best performer in its region, the
U5MR would decline substantially faster, to 132 deaths
per 1000 livebirths in 2030, and 494 million children
would die worldwide in 201630.
Under SDG target scenario four, if every country in the
world managed to reach the SDG target of 25 or fewer
under-5 deaths per 1000 livebirths by 2030, the global
U5MR would fall to 172 deaths per 1000 livebirths,
and 560 million children would die in the next
15 years128 million fewer compared with the current
trends scenario and 66 million more compared with the
best regional performer scenario.
At present, 79 countries have a U5MR that is higher
than the SDG target of 25 per 1000 livebirths. Of these,
32 need to maintain their current rate of progress but
47 need to accelerate progress to achieve the SDG target
(gure 5). Of these 47 countries, 21 are in west and central
Africa, 11 in eastern and southern Africa, and two in south
Asia. 11 countries (Afghanistan, Angola, Central African
Republic, Chad, Comoros, Benin, Kiribati, Lesotho,
Mauritania, Pakistan, and Somalia) will need to at least
triple their rate of reduction to meet the SDG target while
a further 19 will need to make progress at between two and
three times the current pace. Among all low-income
countries, 68% need to accelerate progress. The proportion
drops to 38% among lower-middle-income countries and
10% among upper-middle-income countries.
More ambitiously, if every country in the world
managed by 2030 to reduce its U5MR to the average of
that in high-income countries (ie, scenario ve), the
global U5MR would then be as low as 61 deaths per
1000 livebirths and the total number of under-5 deaths
would be 354 million in 201630 (table 2).

Nigeria

Democratic
Republic of
the Congo

10

Under-5 deaths
(in millions)
0

Sierra Leone
Mali

02
04
Pakistan

08
12

Ethiopia

India

Tanzania
4
Bangladesh
2

Indonesia
China

0
0

10

12

Observed ARR in under-5 mortality rate during 200015

Figure 5: The ARR needed to meet the SDG target of an under-5 mortality rate of 25 deaths per
1000 livebirths by 2030 compared with the ARR observed in 200015
For countries that have already reached the target, the required ARR is set as zero. Each bubble represents a
country, with the size of the bubble representing the number of under-5 deaths in 2015. Labelled countries are the
ten with the largest number of deaths and those with the highest ARR needed. ARR=annual rate of reduction.

The under-5 mortality estimates indicate that in

200015, about 48 million more children survived to age
5 years that would not have done so had the U5MR
remained at the level estimated for the year 2000. About
37 million of these averted deaths are from the period
200013. This estimate is similar to that from the study
by Murray and Chambers20 who concluded that more
than 34 million childrens lives have been saved in 2000
13 because of investments in child health programmes.
Moreover, our estimates show that 18 million of the
additional 48 million lives saved were attributable to the
acceleration in progress since 2000; most of these
children (70%) live in sub-Saharan Africa.
Despite substantial gains in reducing mortality,
progress has been insucient to achieve MDG 4. The
53% decline in the U5MR globally is far from the
two-thirds reduction needed to meet the MDG 4 target. If
current trends continue, the MDG 4 target worldwide
would be reached by 2026more than 10 years behind
schedule. The toll of under-5 deaths over the past two
decades is large: between 1990 and 2015, an estimated
2363 million (2337 million2402 million) children
worldwide died before their fth birthdaymore than
todays population of Brazil, the fth most populous
country. The UN IGME estimates show that had the

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Articles

necessary steady progress been made since 2000 to

achieve the MDG 4 target, 14 million more children
would have survived to age 5 years since 2000.16
Child survival remains an urgent concern. It is
unacceptable that about 16 000 children still die every
day, equivalent to 11 deaths every 1 min. Without any
acceleration in the pace of reduction in child mortality
(projection according to scenario two), 688 million
children would die before they reach their fth birthday
in the next 15 years, with 36 million of these lives lost in
the year 2030 alone. These results correspond to the
ndings from the study by Wang and coauthors13 who
projected that 38 million children could be expected to
die in 2030 if the present rates of change continue
according to the UN Population Division fertility
projections. These numbers are unacceptably high. For
countries that have made very rapid progress since 2000
(eg, Rwanda, Estonia, Cambodia, and China), simply
maintaining the current rate of reduction would be
remarkable and these countries might need even more
investment to do so. The alternative projections indicated
what would occur in dierent scenarios, and resulted
in projections of cumulative deaths ranging from
944 million (under scenario one: no change from 2015
mortality rate) to the hypothetical best case scenario of
354 million if all mortality would drop to the current
average U5MR in high-income countries by 2030. The
SDG target scenario resulted in a projection of
560 million deaths by 2030 and would require an
acceleration of progress for most sub-Saharan Africa
countries.
Sub-Saharan Africa currently remains the region with
the highest U5MR, with one in 12 children dying before
his or her fth birthday. If current trends continue,
37 million children in sub-Saharan Africa would die in the
next 15 years, accounting for 53% of the 688 million
deaths under scenario two. In 2030, around six in ten
global under-5 deaths would occur in sub-Saharan Africa.
To achieve the U5MR SDG target, 34 sub-Saharan Africa
countries need to accelerate progress. In addition, extended
eorts are needed to provide the services and interventions
necessary to meet the additional demand generated by a
growing number of livebirths and child population in this
regionthere is a 95% probability that the number of
children under 5 years will grow by an extra 2657 million
(with a median of 42 million), from 157 million in 2015 to
183214 million in 2030.19 Hence, sub-Saharan Africa faces
unique challenges in reducing the number of child deaths.
The number of under-5 deaths in this region might
increase or remain stagnant even with a declining U5MR
if the decline in mortality rate does not outpace the increase
in population, as observed in the 1990s (gure 1). South
Asia is another region in which acceleration in reducing
child mortality is urgently needed. The current average
U5MR in this region is still high (525 deaths per
1000 livebirths in 2015). Three in ten global under-5 deaths
occur in south Asia. Two out of the eight countries in this
10

region, Afghanistan and Pakistan, need to accelerate

progress to achieve the U5MR SDG target.
The enormous progress in child survival in the 24 lowincome and lower-middle-income countries that met the
MDG 4 target (Armenia, Bangladesh, Bhutan, Bolivia,
Cambodia, Egypt, El Salvador, Ethiopia, Eritrea, Georgia,
Indonesia, Kyrgyzstan, Liberia, Madagascar, Malawi,
Mozambique, Nepal, Nicaragua, Niger, Rwanda,
Timor-Leste, Uganda, Tanzania, and Yemen), and the
recent acceleration in ARR in many sub-Saharan African
countries suggests that child mortality can decline rapidly,
even in poor countries, if the political will and resources
exist to maintain long-term focus. In-depth country
studies similar to the Countdown country case study2123
and the Success Factors studies by the Partnership for
Maternal, Newborn, and Child Health, WHO, World
Bank, and Alliance for Health Policy and Systems
Research24 are needed to provide insights on success
factors in improvements in child survival and to provide
evidence on strategies that can be used to accelerate
progress to achieve the SDG target.
Of 195 countries with available estimates, 116 (59%)
have already achieved the SDG target with a U5MR of
25 or fewer deaths per 1000 livebirths. Of low-mortality
countries that achieved this target, a third have a U5MR
that is below ve deaths per 1000 livebirths, and 16 still
have a U5MR higher than 20. If current trends continue,
44 of these low-mortality countries are not expected to
reach the current average U5MR in high-income
countries by 2030, and about 6 million children will die in
these 116 countries between 2016 and 2030. By contrast, if
all these countries, by 2016, reduced their U5MR to the
current lowest level of 23 deaths per 1000 livebirths
observed among countries with more than 10 000 livebirths
in 2015, an additional 4 million children would be saved.
This means there is still work to be done in improving
child survival, even within this group of countries.
Wide gaps in child mortality within countries have
been documented in this group of low-mortality
countries. For example, Brazil is one of the countries that
succeeded in greatly reducing child mortality. The
country as a whole has met MDG 4the U5MR in Brazil
declined from 608 (90% UI 563656) in 1990 to 164
(155173) in 2015, a 73% reduction. Brazil also
managed to reduce regional inequities in child mortality
in the past 25 years,25 but disparities still persist. Although
more than 1000 of roughly 5500 municipalities had a
U5MR of fewer than ve deaths per 1000 livebirths in
2013, in 32 municipalities the U5MR exceeded 80 deaths
per 1000 livebirths. In addition, Indigenous children are
twice as likely to die before reaching their rst birthday
than other Brazilian children.26 In the USA, a child born
in Mississippi is more than twice as likely to die before
the age of 1 year than is a child living in Iowa and
Massachusetts.27 These examples show that for countries
with relatively low mortality, greater eorts to reduce
disparities at the subnational level and across dierent

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Articles

groups are needed to achieve equity in child survival and

lower mortality overall.
Improvements in data availability and advances in
analytical methods over the past two decades have greatly
expanded knowledge of child mortality rates and trends in
the world. Accurate measurement of child mortality is,
however, still challenging because of the poor availability of
high-quality data in many low-income and middle-income
countries. Only about 60 countries have fully functioning
and complete civil registration systems, which can be relied
on as a single source to produce reliable mortality estimates
over time. Household surveys are the main data sources for
most low-income and middle-income countries. For these
countries, mortality estimates are aected by biases and
sampling errors, and are typically not timely10 (about
40 countries do not have child mortality data sources for
2011 onwards). Hence, a limitation of our study is that for
countries and regions that have recently intensied
interventions and investments to reduce their U5MR but
do not have recent data, the true decline over the past
5 years might be greater than we estimate. Estimation of
cause-specic mortality is even more hindered by data
limitations because fewer than 3% of the global causes of
under-5 deaths are medically certied.28 Longer term,
improved monitoring of child mortality requires the
development of complete and accurate civil registration
systems in low-income and middle-income countries to
gather accurate, timely, disaggregated data that can inform
evidence-based decision making, programming, and
planning. In the short term, we will have to continue using
child mortality data from household surveys. In that
context, the next 2020 round of censuses will be crucial
sources of updated sampling frames for nationally
representative household surveys.
To conclude, despite substantial progress in reducing
child mortality since 1990, MDG 4 was not met worldwide
and the unnished business of child survival looms large.
Every childs death represents the loss of a unique human
being. Countries and the international community must
take immediate action to accelerate further the pace
of progress to full childrens rights to health and
development. Without intensied eorts to reduce child
mortality, particularly in the highest mortality areas and
in contexts with persistent inequities, the post-2015 SDG
target will be unattainable. Child survival must remain at
the heart of the SDG agenda.
Contributors
DY and LA conceived the study and provided overall guidance to the
study. DY, LH, and SE prepared the rst draft. All other authors reviewed
results and provided inputs and comments to the Article.
Declaration of interests
We declare no competing interests.
Acknowledgments
We thank Monica Alexander, Fengqing Chao, and Jing Liu for their
assistance in the estimation process of the child mortality rates. Thanks
to Wahyu Retno Mahanani for assistance to the country consultation
process, to Emi Suzuki for her support to the UN IGME work, and to
Jan Beise, Lijuan Kang, and Colleen Murray for help in checking

numbers. Special thanks to members of the Technical Advisory Group

of the UN IGME (Robert Black, Leontine Alkema, Simon Cousens,
Trevor Croft, Michel Guillot, Kenneth Hill, Bruno Masquelier,
Jon Pedersen, and Ne Walker) for providing technical guidance on
child mortality estimation. The content of this article is solely the
responsibility of the authors and does not necessarily represent the
ocial views of UNICEF or those of the institutions to which the
authors are aliated (UNICEF, World Health Organization, United
Nations, University of California, and University of Massachusetts,
Amherst).
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www.thelancet.com Published online September 9, 2015 http://dx.doi.org/10.1016/S0140-6736(15)00120-8