The rate at which young children perish has worsened most disastrously over the past 15 years in Iraq, hard hit by both sanctions and war, and in Botswana, Zimbabwe and Swaziland, devastated by AIDS, according to a report released on Monday by Save the Children. But researchers also found against-the-odds progress in some of the world's poorest nations.
Bangladesh has profoundly improved the chances that a child would survive by promoting family planning, a strategy that has enabled women to have fewer children, space births and strengthen their own health and that of their babies.
Nepal, despite a decade-long Maoist insurgency, has halved the death rate of children under age five. It has enlisted the help of 50,000 mothers, most of them illiterate, who have squeezed vitamin A drops into the mouths of every child, hauled laggards in for vaccinations and even diagnosed pneumonia and dispensed medicines to combat it.
And Malawi, with an extreme shortage of doctors and nurses, has made surprising gains by taking simple steps that require no professional skills, for example distributing nets that protect children from malarial mosquitoes.
"In 2007, when we know what to do and how little it costs, that 28,000 kids are still dying each day is just plain wrong," said David Oot, a public health expert on the team that produced the Save the Children report, State of the World's Mothers: Saving the Lives of Children Under 5.
Despite many hopeful stories, broad progress against infant and child mortality has flagged since international health agencies began a campaign to reduce deaths 25 years ago, the researchers concluded. By the end of the 1980s, global rates of child mortality had fallen 20 percent, and the lives of 12 million children were saved.
"Much of the momentum behind the child survival revolution has now been lost and gains achieved in the 1980s and early 1990s have slowed or reversed," the report says. "Under-5 mortality declined by only 10 percent from the early 1990s to 2000."
Among the 60 developing countries where 94 percent of the child deaths occurred, 20 have either made no progress or have regressed, while 24 have cut death rates of children under five by at least 20 percent.
Iraq experienced the most staggering rise in under-age-five mortality -- 150 percent over 15 years. Since the war began in 2003, deteriorating health services, rising inflation and electricity shortages have worsened living conditions, the report said. In 2005, about 122,000 Iraqi children died before their fifth birthdays.
In countries that progressed, a focus on family planning was central to progress, the report said. In the five countries that made the greatest strides in reducing child deaths -- Egypt, Indonesia, Bangladesh, Nepal and the Philippines -- women's use of contraceptives rose and fertility rates declined.
In those countries, mothers were less likely to be physically depleted by having too many babies in too short a time. With fewer children, families were also able to invest more in the care of each child.
Political will was also an essential ingredient of success -- and in Malawi, Tanzania, Nepal and Bangladesh was even more important than national wealth, the report found. Egypt, which has cut the death rate of children under age five by 68 percent since 1990, more than any other country, has shown a particular commitment to children's health, said the researchers at Save the Children, a nonprofit group, and other experts.
"In words and deed, Egypt has put children more at the center of their social agenda than most other countries," said Ruth Levine, author of Millions Saved: Proven Successes in Global Health, published by the Center for Global Development in 2004.
Egypt has carried out a comprehensive effort to improve the health of mothers and children. It invested in clean water and public health campaigns to teach the importance of hand-washing in disease prevention. It built roads that sped access to hospitals. It renovated dilapidated clinics. It made sure most mothers had midwives or other skilled workers to attend births. It strove to perfect immunization campaign strategies.
"There is a way to do a blanket of public health interventions that is very effective," said Ayman El-Mohandes, a pediatrician and chairman of the Department of Prevention and Community Health at George Washington University's School of Public Health, who served as a consultant on a US-financed maternal and child health program in Egypt.
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