Article 24 of the UN Convention on the Rights of a Child says that state parties should recognise “the right of the child to the enjoyment of the highest attainable standard of health and to facilities for the treatment of illness and rehabilitation of health”. It obliges the state to take measures “to diminish infant and child mortality” and “to combat disease and malnutrition.1
The infant and under-five mortality rates are key indicators of heath and development. They are associated with a broad range of bio-demographic, health and environmental factors which are not only important determinants of child health but are also informative about the health status of the broader population.
The infant mortality rate (IMR) is defined as the probability of dying within the first year of life and refers to the number of babies under 12 months who die in a year per 1,000 live births during the same year. Similarly, the under-five mortality rate (U5MR) is defined as the probability of a child dying between birth and their fifth birthday. The U5MR refers to the number of children under five years old who die in a year per 1,000 live births in the same year.
This information is ideally obtained from vital registration systems. However, as in many middle- and lower-income countries, the under-reporting of births and deaths renders the South African system inadequate for monitoring purposes. South Africa is therefore reliant on alternative methods, such as survey and census data, to measure child mortality. Despite several surveys which should have provided information to monitor progress, the lack of reliable data since 2000 led to considerable uncertainty around the level of childhood mortality for a prolonged period. However, the second South Africa National Burden of Disease Study has produced national and provincial infant and under-five mortality trends from 1997 up until 2012.2
An alternative approach to monitoring age-specific mortality nationally since 2009 is the rapid mortality surveillance system (RMS) based on the deaths recorded on the population register by the Department of Home Affairs.3 These data have been corrected for known biases. In other words, the trends shown are based on nationally representative numbers. The RMS reports vital registration data adjusted for under-reporting which allows for the evaluation of annual trends.
Long-term trends show that the IMR peaked in 2003 when it was 54 per 1,000 and decreased to 27 per 1,000 in 2019 with a further decrease to 21 in 2020. During the same period the U5MR decreased from 81 per 1,000 in 2003 to 36 per 1,000 in 2019 and 28 in 2020.4
With reference to the substantial drop in infant and under-5 mortality in 2020, the authors of the Rapid Mortality Surveillance Report note that “the lack of seasonal increases in the numbers of registered deaths suggest that the winter increases in respiratory syncytial virus (RSV) and other pneumonias as well as seasonal outbreaks of diarrhoea were absent in 2020.”4 This was possibly due to the effects of lockdown with “unusually low” monthly deaths in April and May 2020, and “no seasonal trend in the following [winter] months”.4 In other words, while the hard lockdown of 2020 was devastating for the economy and society in many ways, an unexpected benefit was that the restrictions on socialising and travel may have protected young children from infectious diseases that contribute to high mortality rates.
Preliminary estimates by the MRC suggest that infant mortality rates rose sharply in 2021 and 2022, with a corresponding increase in under-5 mortality. The estimated IMR for 2022 was 30 deaths per 1,000 live births, while the U5MR reached 40. The reasons for rising child mortality after lockdown are unclear as there have been long delays in the release of Causes of Death data by StatsSA. It is partly due to this delay that the MRC has not formally published its child mortality estimates since 2020, although the estimates have been shared with the United Nations Inter-Agency Group for Child Mortality Estimation and incorporated into the UN models. Generally, the leading causes of under-five mortality (other than neonatal causes) are diarrhoea, pneumonia and other respiratory infections, while malnutrition is often an underlying cause of death in young children.
The neonatal mortality rate (NMR) is the probability of dying within the first 28 days of life per 1,000 live births. The NMR has remained stable, at around 12 deaths per 1,000 live births. Estimates of the NMR were derived from vital registration data (i.e., registered deaths and births without adjustment for incompleteness) up to 2013, and from 2013 onwards the estimates were derived directly from neonatal deaths and live births recorded in the Department of Health’s District Health Information System (DHIS). The NMR estimates therefore exclude deaths that occur in private sector health facilities or at home.
The DHIS also records the in-facility neonatal death rate – i.e. the number of infants aged 0-27 days who died during their stay in the facility, per 1,000 live births in public health facilities. The recorded rates were also around 12 in the years leading up to COVID-19 but increased slightly to 13 per 1,000 live births in 2021 and 2022.5
1 Office of the High Commissioner of Human Rights. Convention on the Rights of the Child. UN General Assembly Resolution 44/25. Geneva: United Nations. 1989.
2 Nannan N, Groenewald P, Pillay-van Wyk V, Msemburi W, Dorrington R, Bradshaw D. Child mortality trends and causes of death in South Africa, 1997-2012, and the importance of a national burden of disease study. South African Medical Journal. 2019, 209(7):480-485.
3 Bradshaw D, Dorrington R, Nannan N, Laubscher R. Rapid Mortality Surveillance Report 2013. Cape Town: South African Medial Research Council. 2014.
4 Dorrington R, Bradshaw D, Laubscher R, Nannan N. Rapid Mortality Surveillance Report 2019 & 2020. Cape Town: South African Medical Research Council. 2021.
5 Ndlovu N, Gray A, Mkhabela B, Myende N, Day C. Health and related indicators 2022 In: Padarath A, Moeti TL, editors. South African Health Review 2022: Health systems recovery after COVID-19. Durban: Health Systems Trust; 2023.