Child mortality in Iran's provinces: successes and future needs.

In The Lancet Global Health, Younes Mohammadi and colleagues present an estimate of the change in under-5 child mortality rate (CMR) from 1990 to 2015 in Iran. The dramatic 70% reduction means that Iran as a whole achieved Millennium Development Goal 4 (MDG4) and was one of the best performers in the Middle East and North Africa region in absolute reduction of CMR during the past four decades. The figure is also higher than the worldwide estimate of a 52·0% decrease in CMR as provided by the Global Burden of Disease Study (2015). Mohammadi and colleagues used five empirical data sources and strict eligibility criteria for their report, and also conducted sophisticated analyses to overcome the crucial problem of the low quality of some databases and the high percentages of missing data in some surveys. Although, in the absence of a comprehensive vital registration system in Iran, this study could not directly calculate CMR, its estimates do present an overview of national trends. Moreover, this paper compares the CMR trends across different provinces, which vary considerably in their sociodemographic characteristics. By this measure, the reduction in CMR was not so remarkable: five provinces did not achieve MDG4. Mohammadi and colleagues attribute this to the low human development index at the beginning of the millennium in these provinces, as well as a lower density of health-care providers in comparison with the other 25 provinces. The health-care reforms that have been implemented recently in Iran might be effective, at least in part, in reducing these disparities in the near future. However, because in Iran CMR is inversely associated with low education of mothers and low community socioeconomic status, as it is for many other countries, different aspects of social improvement will be necessary for further reduction of CMR in disadvantaged regions. Given the increasing concern about equity in child survival, it is also necessary to improve the registry and monitoring systems for CMR at the subnational level. Mohammadi and colleagues’ study suggests that the impressive reduction in CMR at the national level and in most provinces is mainly attributed to improvements in access to health-care services and improved hygiene. However, better hospital care, notably rapid improvements in treatment modalities for neonates who need intensive medical attention and the expansion of paediatric emergency departments, should also be taken into account. Health policy makers need detailed and updated information about CMR; therefore future research should provide age-specific estimates in under-5 mortality in the neonatal and post-neonatal periods, as well as at ages 1–4 years. Moreover, cause-specific mortality, congenital anomalies, and stillbirths should be registered over time.