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OCR for page 153
Demographic Change in Sub-Saharan Africa
5
Trends in Childhood Mortality
Althea Hill
INTRODUCTION
A broad, comparative outline of levels, patterns, and trends in childhood mortality across the African continent was presented in a paper written in 1987 and published recently (Hill, 1989, 1991, 1992). That paper covered sub-Saharan mainland Africa between roughly the late 1940s and the late 1970s and made use of all the data on child survival available at the time of writing. The overall findings are summarized in Figures 5–1 and 5–2, which display summary estimates over time for all countries possessing usable data.
Four major features, all clearly visible in the figures, emerged from the findings of that paper. These were
declines in childhood mortality since World War II in almost all countries for which data were available;
much variation among countries in the type of decline;
much variation among countries in the level of childhood mortality in all periods; and
a marked overall difference in mortality levels between countries in western and middle Africa and countries in eastern and southern Africa,
Althea Hill is at the India Country Department, Population and Human Resources Division, The World Bank.
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Demographic Change in Sub-Saharan Africa
FIGURE 5–1 Risk of dying before age 5, western and middle Africa, 1926–1980. SOURCE: Hill (1991: Figure 3–2).
with a rough gradient running from higher mortality in the northwest to lower mortality in the southeast of the continent.
With regard to this last point, there were indications that this gradient, having been very distinct at the start of the period of study, was becoming progressively blurred as more and more western and middle African countries reduced their mortality levels to near or within the eastern and southern range. However, the picture was still too indefinite for firm conclusions at that time.
The paper also noted three exceptions to these general patterns:
Some countries had experienced periods of static or rising mortality, almost all against a background of civil war and disruption of normal socioeconomic development (e.g., Ethiopia, Mozambique, Rwanda, and Sudan).
The mortality of a few western and middle African countries (notably Ghana, Congo, and Cameroon) had fallen to well within the eastern and southern range.
One eastern African country, Malawi, had a level of mortality toward the upper end of the western and middle African range.
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Demographic Change in Sub-Saharan Africa
FIGURE 5–2 Risk of dying before age 5, eastern and southern Africa and Sudan, 1926–1980. SOURCE: Hill (1991: Figure 3–3).
DATA DEVELOPMENTS SINCE 1987
In 1987, when the aforementioned review of levels and trends in childhood mortality in Africa was prepared, almost no data on developments in the 1980s were yet available. As shown in Table 5–1, several censuses and surveys had indeed been carried out between 1980 and 1987, but very few of them had yet yielded available results. Over the last five years, however, a considerable quantity—though by no means all—of new data collected during the 1980s has been released. This chapter reviews levels and trends in many of the countries for which fresh data are available for analysis, and examines whether the conclusions of the previous review still hold both at country and at continental levels.
In total, new national-level data are available for 16 countries (about 40 percent of all mainland sub-Saharan countries); these are Botswana, Burkina Faso, Burundi, Côte d’Ivoire, The Gambia, Ghana, Kenya, Liberia, Malawi, Mali, Nigeria, Senegal, Sudan, Togo, Zaire, and Zimbabwe. Data are also available for a large part of Uganda. In addition, data from small-
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Demographic Change in Sub-Saharan Africa
TABLE 5–1 African Censuses and Surveys Since 1980
Country
Type of Operationa
Date
Status of Mortality Data
Western
Benin
WFS
1981
Published
Burkina Faso
Censusb
1985
Available
Côte d’Ivoire
WFSb
1980–1981
Published
LSMS
1985–1986
Partly available
Censusb
1988
Available
The Gambia
Censusb
1983
Published
Ghana
Census
1984
Not collected
LSMS
1987–1988
Not yet available
DHSb
1988
Published
Guinea
Census
1983
Abandoned
Guinea-Bissau
Census
1979
Not yet available
Liberia
Census
1984
Partly available
DHSb
1986
Published
Mali
Censusb
1987
Available
DHSb
1987
Published
Niger
Census
1988
Available
Nigeria
Demographic survey
1980–1981
Unavailable
WFSb
1981–1982
Published
DHS (Ondo State)
1987
Published
DHS (national)b
1990
Available
Senegal
DHSb
1986
Published
Census
1988
Partly available
Sierra Leone
Census
1985
Not yet available
Togo
Census
1981
Not collected
DHSb
1988
Published
Middle
Angola
Census (Luanda only)
1983–1984
Available
Southeast region surveyb
1988
Available
Cameroon
Census
1987
Partly available
DHS
1991
Available
Congo
Census
1984
Partly available
Zaire
CPS (small area)
1984
Published
Censusb
1984
Partly available
Eastern
Burundi
DHSb
1987
Published
Census
1990
Not yet available
Ethiopia
Demographic survey
1980–1981
Published
Census
1984
Not yet available
National demographic survey
1990
Partly available
Kenya
National demographic surveyb
1983
Partly available
CPS
1984
Published
DHSb
1989
Published
Census
1989
Not yet available
Malawi
National demographic surveyb
1982
Published
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Demographic Change in Sub-Saharan Africa
Country
Type of Operationa
Date
Status of Mortality Data
WFS typeb,c
1984
Published
Census
1987
Partly available
Mozambique
Censusb
1980
Available
WFS typeb,c,e
1987
Partly available
Rwanda
WFS typec
1983
Published
Somalia
Demographic survey
1980
Published
Census
1986–1987
Possibly lost
Tanzania
Census
1988
Partly available
Uganda
Census
1980
Mostly lost
DHS (south only)b
1988–1989
Published
Zambia
Census
1980
Not published
DHS
1992
Partly available
Zimbabwe
Censusb
1982
Partly published
CPSb
1984
Published
Demographic surveyb
1987
Partly published
DHSb
1988
Published
Southern
Botswana
Censusb
1981
Published
CPSb
1984
Published
Demographic survey
1987
Not yet available
DHSb
1988
Published
Lesotho
Census
1986
Not yet available
Swaziland
Census
1986
Not yet available
DHS typed
1986
Not yet available
Northern
Sudan
Censusb
1983
Available
DHS (northern only)b
1989–1990
Published
aWFS: World Fertility Survey; LSMS: Living Standards Measurement Survey; DHS: Demographic and Health Survey; CPS: Contraceptive Prevalence Survey.
bData set used in this chapter.
cSurvey modeled after WFS, but not part of the WFS series.
dSurvey modeled after DHS, but not part of the DHS series.
eData from Maputo, the capital city, are used here.
scale surveys in Mozambique and Angola are examined, because of the particular interest and data scarcity in those two countries.
The methodology employed is the same as for the previous review (see appendix A to this chapter). The mainstay of the analysis is information on child survival, collected from mothers in censuses and surveys and analyzed by using the Trussell variant of the Brass child survival method (Trussell, 1975); estimates based on Coale-Demeny North and South families of life tables (Coale and Demeny, 1983) are compared, and those that appear to fit
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Demographic Change in Sub-Saharan Africa
Summary estimates of dying before age 5 (per 1,000), selected African countries between 1979 and 1985.
the data best are selected.1 Direct data on child deaths from maternity histories are used for evaluation but not for the final estimates. More methodological details are given in Hill (1989, 1991, 1992).
1
Coale and Demeny developed four model life table families (East, West, North, and South) to reflect the different age and sex patterns of mortality derived from historical data from eastern-central, northwestern, Scandinavian, and southern countries of Europe, respectively. The North and South models provide the best fit for the African age pattern of mortality in childhood (see the appendix to this chapter for details). Estimates based on these two models are given in the appendix B tables for each country discussed. In some cases, the estimates from both models are also presented in the figures; however, because of space limitation, only one of the models is usually presented in a figure.
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Demographic Change in Sub-Saharan Africa
Every stage of the analysis and estimation for each country is standardized as much as possible in order to put individual country results into a framework of continental levels, patterns, and trends. Inevitably, estimation from large quantities of imperfect data is a subjective process in which individual judgment must play a large part. (See map for summary of continental levels of child mortality.)
NEW COUNTRY DATA AND RESULTS
Botswana and Zimbabwe
These two countries are examined together because they are neighbors, their levels of overall development are very similar, their mortality levels and trends were also very similar up to 1980 (see Figure 5–2), and their data collection schedules in the 1980s were almost identical. They each had a census at the beginning of the decade, a Contraceptive Prevalence Survey (CPS) in 1984, an intercensal demographic survey (ICDS) in 1987 (unfortunately not yet available for Botswana), and a Demographic and Health Survey (DHS) in 1988.
The results of the analysis of all available mortality data for both countries are presented in Tables 5–B.1 and 5–B.2 of appendix B, and are shown graphically in Figures 5–3, 5–4, and 5–5. In both, there is a marked contrast between the smoothness and regularity of the census results and the irregular, seesaw, and often rather wild results from various surveys; no doubt the much larger numbers available for analysis from the census are largely responsible. However, the consistency and plausibility of the results from the 1980s survey data differ sharply between the two countries.
For Botswana, provided the South model is used, all the data except the direct DHS reports are highly consistent. They show a continued decline in childhood mortality from 1955 to 1985, with the decline possibly accelerating during the late 1970s and early 1980s. Because Botswana enjoyed rapid economic growth and fast-developing infrastructure and social services throughout the 1970s and 1980s, such a trend is not at all surprising. The very low level of mortality achieved by the mid-1980s—a probability of dying by age 5 of not much more than .050, which implies an infant mortality rate between 30 and 40 deaths per 1,000 live births—should also be acceptable because the DHS shows that child health and nutrition are excellent. Botswana appears now to have perhaps the lowest mortality in sub-Saharan Africa.
By contrast, the 1980s survey data for Zimbabwe are confused and inconsistent, with the exception of the larger-scale 1987 demographic survey of the traditional type, which fits well with the two sets of census data. The 1984 CPS results not only are highly irregular in trend—first steeply up
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Demographic Change in Sub-Saharan Africa
FIGURE 5–3 Risk of dying before age 5, Botswana, 1955–1990, South model. SOURCES: 1971 census (Botswana, 1972); 1981 census (Botswana, 1983); 1984 Contraceptive Prevalence Survey (CPS) (Botswana, 1985); 1988 Demographic and Health Survey (DHS) (Lesetedi et al., 1989).
FIGURE 5–4 Risk of dying before age 5, Zimbabwe, 1950–1990, North model. SOURCES: 1969 census (Rhodesia, n.d.); 1982 census (Zimbabwe, 1985a); 1984 Contraceptive Prevalence Survey (CPS) (Zimbabwe, 1985b); 1987 Intercensal Demographic Survey (ICDS) (Zimbabwe, 1991); 1988 Demographic and Health Survey (DHS) (Zimbabwe, 1989).
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Demographic Change in Sub-Saharan Africa
FIGURE 5–5 Risk of dying before age 5, Zimbabwe, 1950–1990, South model. SOURCES: 1969 census (Rhodesia, n.d.); 1982 census (Zimbabwe, 1985a); 1984 Contraceptive Prevalence Survey (CPS) (Zimbabwe, 1985b); 1987 Intercensal Demographic Survey (ICDS) (Zimbabwe, 1991); 1988 Demographic and Health Survey (DHS) (Zimbabwe, 1989).
and then even more steeply down, all in the space of less than 15 years—but appear quite at odds with all the other data. The 1988 DHS mortality levels are much too low compared with the other data sources, except perhaps in the most recent few years. The best choice seems to be a combination of the 1987 demographic survey results with those of the two censuses, which would also yield mortality levels similar to those from the DHS around the mid-1980s. North appears the better-fitting model for the two censuses, but South gives better consistency thereafter; there seems no clear-cut reason to prefer one over the other.
The resulting trend is again of a continued mortality decline from the early 1970s to the mid-1980s, gentle at first, then with perhaps an acceleration of decline in the 1980s; there is also a hint in the data of some temporary stagnation or rise in mortality during the late 1970s, the period of the war for independence. The relatively low overall level of childhood mortality achieved by the mid-1980s—a probability of dying by age 5 of about .080 to .090—is again consistent with Zimbabwe’s good general level of income and development and the excellent child health and nutrition noted in the DHS. Such a level would place Zimbabwe behind Botswana, but still among the very lowest-mortality countries in Africa.
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Demographic Change in Sub-Saharan Africa
Middle and Eastern Africa
Mozambique and Angola, the two major former Portuguese colonies, have enjoyed neither stability nor solid economic growth for many years. In both, a long and painful war for independence was followed by a short period of relative peace before internal conflicts resumed. No new national-level data for the 1980s are yet available for Mozambique, and none were collected in Angola. Survey data from two small areas in the southern parts of these countries are, however, available and are presented in this chapter. These are Maputo, the capital city of Mozambique (data from a 1987 national World Fertility Survey (WFS) type of survey), and rural parts of the southwest region of Angola bordering on Namibia (data from a local socioeconomic-demographic survey in 1988). The results from these new data sets, combined with the latest available national data, are shown in Tables 5–B.3 and 5–B.4, and summarized graphically in Figures 5–6 and 5–7.
The trend in childhood mortality in Maputo between the early 1970s and the mid-1980s is broadly consistent with the picture already evident in the national census results. There was possibly a mortality decline through the earlier 1970s (when the Portuguese were still developing Maputo as a modern city headquarters containing a major concentration of the Portuguese settler population), followed by stagnation from the mid-1970s through
FIGURE 5–6 Risk of dying before age 5, Mozambique and Maputo, 1960–1990, North and South models. SOURCES: 1980 census (Mozambique, n.d.); 1987 Maputo Fertility Survey (MFS) (WFS-type survey) (Mozambique, 1987).
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Demographic Change in Sub-Saharan Africa
FIGURE 5–7 Risk of dying before age 5, Angola and southwestern Angola, North and South models. SOURCES: 1940 census (Heisel, 1968); 1988 rural survey (Angola, 1990).
the mid-1980s, during which the Portuguese withdrawal was followed by the onset of a crippling civil war. The overall level of childhood mortality in Maputo during the late 1970s and 1980s was, however, relatively low, with a probability of dying by age 5 of .120 to .140—much lower than the corresponding level of .270 to .280 for Mozambique as a whole.
The picture in southwestern Angola is even worse. Rural pastoral and agricultural populations appear to have experienced stagnating or rising childhood mortality from 1970 to the mid-1980s, even though this area was relatively prosperous and least affected by the postindependence civil war. According to the analysis of the 1940 census reported in Brass et al. (1968), the region, then called Huila, enjoyed by far the lowest childhood mortality in Angola at that time. The childhood mortality estimates emerging from the 1988 rural survey, with probabilities of dying by age 5 of .200 to .250, represent an improvement over the levels found in the 1940 census data, but are still very high given the area’s location in the lowest-mortality part of Africa.
Full results from the Malawi census of 1987 are not yet available. However, given Malawi’s extraordinarily severe childhood mortality in earlier periods—probabilities of dying by age 5 of .330 to .370, which are high for any part of sub-Saharan Africa (see Figures 5–1 and 5–2) —it is of interest to examine the additional data on trends from the mid-1960s to the beginning of the 1980s that emerge from the two surveys carried out in
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Demographic Change in Sub-Saharan Africa
TABLE 5–B.15 Child Survival Analysis Results, Ghana
Coale-Demeny North Model
Coale-Demeny South Model
Data Set
Reference Date
Probability of Dying Before Age 5
Reference Date
Probability of Dying Before Age 5
1948 census
1934.00
.3555
1933.21
.3800
1936.64
.3432
1936.10
.3624
1938.84
.3543
1938.45
.3700
1940.86
.3321
1940.58
.3467
1942.80
.2915
1942.63
.3004
1944.61
.2483
1944.56
.2460
1960 census
1945.99
.2632
1945.14
.2876
PESa
1948.75
.3242
1948.16
.3446
1951.22
.2541
1950.80
.2693
1953.52
.2453
1953.24
.2555
1955.63
.2391
1955.49
.2426
1957.50
.2310
1957.47
.2247
1970 census
1957.02
.2196
1956.14
.2436
PESa
1959.91
.2141
1959.28
.2333
1962.61
.2076
1962.17
.2219
1965.13
.2082
1964.86
.2162
1967.38
.1981
1967.26
.1982
1969.27
.1918
1969.26
.1826
1979–1980 WFS
1964.98
.1488
1964.09
.1702
1967.87
.1369
1967.22
.1524
1970.58
.1232
1970.13
.1341
1973.11
.1280
1972.84
.1331
1975.38
.1254
1975.27
.1242
1977.30
.1507
1977.29
.1417
1988 DHS
1974.34
.1679
1973.52
.1895
1977.20
.1513
1976.63
.1668
1979.75
.1499
1979.36
.1611
1982.07
.1613
1981.83
.1668
1984.15
.1613
1984.04
.1605
1985.90
.1751
1985.89
.1662
Reference Date
Equivalent Value of q5
1988 DHS
1973–1977
.1872
Direct data
1978–1982
.1524
1983–1987b
.1547
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Demographic Change in Sub-Saharan Africa
Coale-Demeny North Model
Coale-Demeny South Model
Data Set
Reference Date
Probability of Dying Before Age 5
Reference Date
Probability of Dying Before Age 5
1979–1980 WFS
1949–1953
.213
Direct data
1954–1958
.172
1959–1963
.145
1964–1968
.148
1969–1973
.118
1974–1978
–
aPostenumeration survey.
bIncludes exposure during 1988 up to the month preceding the interview.
SOURCES: 1948 census (Ghana, 1948); 1960 census postenumeration survey (PES) (Gaisie, 1969); 1970 census postenumeration survey (PES) (Ramachandran, 1979); 1979–1980 World Fertility Survey (WFS) (Owusu, 1984); 1988 Demographic and Health Survey (DHS) (Ghana, 1989).
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Demographic Change in Sub-Saharan Africa
TABLE 5–B.16 Child Survival Analysis Results, Togo
Coale-Demeny North Model
Coale-Demeny South Model
Data Set
Reference Date
Probability of Dying Before Age 5
Reference Date
Probability of Dying Before Age 5
1961 census
1947.82
.3334
1947.01
.3582
PESa
1950.64
.3188
1950.08
.3383
1953.12
.3282
1952.73
.3431
1955.37
.3249
1955.13
.3365
1957.42
.3271
1957.30
.3325
1959.18
.3171
1959.16
.3150
1971 census
1957.18
.2759
1956.34
.3003
PESa
1960.04
.2636
1959.45
.2832
1962.64
.2596
1962.23
.2743
1965.02
.2414
1964.77
.2501
1967.16
.2423
1967.05
.2433
1968.96
.2190
1968.95
.2101
1988 DHS
1974.72
.1781
1973.90
.2001
1977.57
.1875
1977.00
.2047
1980.09
.1717
1979.70
.1837
1982.39
.1808
1982.15
.1870
1984.46
.1558
1984.36
.1551
1986.22
.1560
1986.21
.1473
Reference Date
Equivalent Value of q5
1988 DHS
1973–1977
.2056
Direct data
1978–1982
.1590
1983–1988
.1582
aPostenumeration survey.
SOURCES: 1961 census postenumeration survey (PES) (United Nations, 1978); 1971 census postenumeration survey (PES) (Adognon, 1980); 1988 Demographic and Health Survey (DHS) (Agounké et al., 1989).
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Demographic Change in Sub-Saharan Africa
TABLE 5–B.17 Child Survival Analysis Results, Côte d’Ivoire
Coale-Demeny North Model
Coale-Demeny South Model
Data Set
Reference Date
Probability of Dying Before Age 5
Reference Date
Probability of Dying Before Age 5
1978–1979 multiround NDS
1964.50
.2557
1963.70
.2790
1967.19
.2513
1966.65
.2696
1969.47
.2390
1969.09
.2531
1971.55
.2773
1971.29
.2885
1973.51
.2158
1973.36
.2187
1975.28
.2016
1975.25
.1954
1980–1981 WFS
1966.21
.2433
1965.33
.2677
1968.99
.2248
1968.37
.2441
1971.53
.2127
1971.08
.2275
1973.91
.2018
1973.62
.2107
1976.10
.2018
1975.96
.2040
1978.03
.1919
1978.00
.1843
1988 census
1973.75
.1859
1972.91
.2085
1976.48
.1792
1975.89
.1963
1978.91
.1612
1978.48
.1735
1981.16
.1481
1980.87
.1545
1983.26
.1394
1983.11
.1402
1985.14
.1428
1985.11
.1355
Reference Date
Equivalent Value of q5
1980–1981 WFS
1960–1964
.287
Direct data
1965–1969
.255
1970–1974
.243
1975–1979
.176
SOURCES: 1978–1979 National Demographic Survey (NDS) (Côte d’Ivoire, n.d.); 1980–1981 World Fertility Survey (WFS) (Côte d’Ivoire, 1984); 1988 census (unpublished data).
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Demographic Change in Sub-Saharan Africa
TABLE 5–B.18 Child Survival Analysis Results, Liberia
Coale-Demeny North Model
Coale-Demeny South Model
Data Set
Reference Date
Probability of Dying Before Age 5
Reference Date
Probability of Dying Before Age 5
1970
1953.72
.3089
1952.66
.3384
NDS, round one
1956.57
.2915
1955.75
.3169
1959.56
.2622
1958.95
.2829
1962.52
.2509
1962.12
.2660
1965.23
.2638
1965.05
.2715
1967.60
.2840
1967.57
.2809
1971
1956.70
.3289
1955.81
.3550
NDS, round two
1959.46
.3029
1958.83
.3238
1961.99
.2919
1961.54
.3085
1964.37
.2953
1964.07
.3086
1966.58
.2775
1966.42
.2839
1968.53
.2802
1968.50
.2776
1974 census
1959.79
.2376
1958.91
.2620
1962.48
.2400
1961.85
.2600
1964.92
.2240
1964.45
.2397
1967.23
.2234
1966.91
.2345
1969.41
.2081
1969.23
.2127
1971.41
.1777
1971.37
.1719
1986 DHS
1972.01
.2372
1971.17
.2610
1974.76
.2211
1974.17
.2397
1977.20
.2344
1976.78
.2491
1979.45
.2194
1979.18
.2285
1981.54
.2486
1981.40
.2526
1983.40
.2501
1983.36
.2451
Reference Date
Equivalent Value of q5
1986 DHS
1971–1975
.275
Direct data
1976–1980
.243
1981–1986
.220
SOURCES: 1970–1971 National Demographic Survey (NDS) (Massalee, 1974; United Nations, 1978); 1974 census (Liberia, 1977); 1986 Demographic and Health Survey (DHS) (Cheih-Johnson et al., 1988).
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Demographic Change in Sub-Saharan Africa
TABLE 5–B.19 Child Survival Analysis Results, Nigeria
Coale-Demeny North Model
Coale-Demeny South Model
Data Set
Reference Date
Probability of Dying Before Age 5
Reference Date
Probability of Dying Before Age 5
1981–1982
WFS
1966.92
.1729
1965.97
.1961
1969.81
.1778
1969.10
.1964
1972.63
.1570
1972.12
.1703
1975.31
.1427
1975.00
.1492
1977.74
.1596
1977.60
.1601
1979.80
.1876
1979.78
.1787
1990 DHS
1976.83
.1974
1976.04
.2197
1979.64
.1972
1979.10
.2143
1982.05
.1979
1981.68
.2105
1984.23
.1862
1981.00
.1926
1986.21
.1937
1986.10
.1939
1987.92
.2228
1987.89
.2149
Reference Date
Equivalent Value of q5
1990 DHS
1975.5–1980.5
.2009
Direct data
1980.5–1985.5
.1891
1985.5–1990.5
.1924
SOURCES: 1981–1982 World Fertility Survey (WFS) (unpublished data); 1990 Demographic and Health Survey (DHS) (Nigeria, 1992).
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REFERENCES
Adognon, K. 1980 L’evolution de la fécondité dans les années soixante (1961–1971) au Togo. In Actes du Colloque de Démographic d’Abidjan (22–26 janvier 1979), Tome 1, Fécondité. Abidjan: Institut de Formation et de Recherche Démographiques.
Agounké, A., M.Assogba, and K.Anipah 1989 Enquête Démographique et de Santé au Togo, 1988. Lomé: Unité de Recherche Démographique, Direction de la Statistique, Direction Générale de la Santé; Columbia, Md.: Institute for Resource Development/Macro Systems, Inc.
Angola 1990 Famílias e aldeias do sul de Angola: análise dum inquérito socio-económico e demográfico nas Zonas rurais da regiao Sal-Sudoeste. Institute Nacional de Estatistica Unidade de Analise demografica. República Popular de Angola.
Botswana 1972 Report on the Population Census, 1971. Gabarone: Central Statistical Office.
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Representative terms from entire chapter:
south model
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