Every 4.4 seconds in 2021, a child or young person died. About 5 million children died before their fifth birthday, and another 2.1 million died between the ages of 5 and 24. Most of those deaths could have been prevented, according to the United Nations report, "Levels and Trends in Child Mortality," released January 10.

What's more heartbreaking than those figures is that a child's chance at survival depends on where they're born. In North America, 6 children per 1,000 die before their fifth birthday. In sub-Saharan Africa and South Asia, the rates of deaths of infants and children — the under-5 mortality rates — are 74 per 1,000 and 37 per 1,000, respectively. Those areas together account for 70% of childhood deaths in the world.

Globally, the under-5 mortality rate is 38 per 1,000; that's half what it was in 2000. The mortality rate for older children and youth dropped by 37% since 2000, as well, as many countries geared up to follow World Health Organization guidelines. But since 2010, annual improvements have slowed. It's an open question whether more children will die of preventable diseases in the next few years because of COVID-19 related interruptions in health-care delivery and vaccine programs. During the years of the pandemic, vaccinations against measles, pertussis and other preventable diseases plummeted.

We talked about the report with Dr. Tijani Salami, who works in Nigeria on maternal and child health and who is pursuing an additional degree at Johns Hopkins Bloomberg School of Public Health. This interview has been edited for length and clarity.

The good news in this report is the continued decline in childhood mortality worldwide. What is most worrisome about the report?

The World Health Organization has a goal of reducing infant mortality rates to 12 per 1,000 and under-5 mortality rates to 25 per 1,000 by 2030. Many North American and European countries have already reached that goal. But there is a high level of disparity, and [in] Sub-Saharan Africa and South Asia, especially Pakistan and India, [the numbers] are still a problem.

Why are these regions still experiencing such high rates of young deaths?

It begins with unaddressed problems in pregnancy. A lack of education about pregnancy means that sometimes the woman doesn't notice warning signs. She might not know that she has high blood pressure or anemia [which could put both mother and baby's life at risk]. So she doesn't go in for a check-up.

The mother's untreated health problems can put her baby at risk, even lead to the infant's death. But what if she does recognize that she requires health care?

Many women, especially in rural areas, cannot easily get to a hospital. It's days before she can get there. The family, the husband, friends, they must carry the woman and trek her all the way to a clinic. If they take vehicles, most times it's motorcycles, because other vehicles cannot access many rural areas. The trek worsens the woman's condition.

There are often further delays when they get to a clinic. Some facilities don't operate 24 hours. Workers are often overwhelmed with patients.

So delays in care are a big factor. What about the care the patients eventually get in some of the poorest regions of the world?

There is an overall lack of skilled workers. Hospitals and clinics should have trained community health workers and a midwife. But many times, you see workers who are not that skilled dealing with serious pregnancy problems.

Even if there are skilled workers, there is a lack of emergency drugs that could be used to arrest bleeding, for transfusion, or to stop contractions in false, early labor. They may not have oxygen, which is very important because breathing problems are very common [in newborns].

When the baby is born, they may have sepsis, [which is] a form of infection, or pneumonia. These require the right drugs, antibiotics, and oxygen [to keep the baby alive and well.] Many facilities lack those basic things.

There are pockets of high childhood mortality even in wealthy nations. What accounts for that?

Most of the wealthiest countries have done well, but there is a challenge with the United States. There are gaps in access to health care in the United States not seen in other developed countries. Infants born to Black women are more than two times at risk of death compared to whites. [Infant mortality rates are 10.6 per live births for Blacks compared to 4.5 per 1,000 for whites.]

What about children who survive infancy?

Preventable childhood diseases are killing children under 5: measles, tuberculosis, pertussis and pneumonia. Malaria, which can be prevented with mosquito netting as well as with some drugs, kills children when those things are not available.

Malnutrition is common. It's estimated that 17 million children in Nigeria are malnourished. They don't have access to eggs, meat, fish. They don't have enough protein. There is an intervention called Plumpy'Nut, [a peanut-based, high protein paste], but it's not always available.

Of the 6.7 million people worldwide who have died of COVID-19, only about 16,000 were children under the age of 20, so the direct effect of the pandemic on childhood mortality is minimal. What do you think will be the indirect effect of the pandemic on childhood mortality?

There have been disruptions in access to health care and in vaccinations [to prevent childhood diseases like measles] because of COVID. Whether that has contributed to childhood mortality is highly debated because the report said there were few child deaths directly attributed to COVID. But indirect deaths, as a result of these disruptions, will only be seen in the long term. If nothing is done to get more children vaccinated, we're going to see an increase in childhood mortality in the next five years.

The report also addresses mortality rates among children and young people aged 5 to 24. How are those youth dying?

A lot of the deaths can be attributed to sexual and reproductive health. Many young people don't have access to family planning, so there are complications from teen pregnancies and unsafe abortions. Drug use is a crisis in many regions, and violence. In Nigeria, we have kidnapping for ransom, and youth against youth, community against community violence, like gangs. The root cause of this is unemployment and lack of education.

What can be done?

Countries need to provide a continuum of care from pregnancy through delivery, to build more clinics along with teams of health-care providers, to provide more equipment and resources in hospitals. We need to invest in tracking the health of every child at least to the age of 5 to see that they are vaccinated and not malnourished.

I don't see it getting better any time soon.

Susan Brink is a freelance writer who covers health and medicine. She is the author of The Fourth Trimester and co-author of A Change of Heart.