6. Incorporating Deaths Near the Time of Birth into Estimates of the Global Burden of Disease

Abstract

Many countries maintain vital registration systems that provide data on deaths by cause, sex, and age, and some also report years of life lost because of premature mortality (YLL) resulting from each cause. The tracking of stillbirths, however, is often incomplete and variable.

In the early 1990s, no estimates of YLL were available for many developing countries or regions. In 1993, the World Bank initiated an effort to generate estimates that have subsequently been used to guide resource allocation in the health sector. Nevertheless, the global burden of disease literature provides little insight into the importance of deaths near the time of birth.

In 2001, 10.6 million children died before their fifth birthday. Of these, 3.9 million deaths occurred in the neonatal period, under the age of 28 days. Another 3.3 million stillborn children remained outside the vital registration systems of most countries. With stillbirths included, about half of all deaths of children under age five occur under the age of 28 days.

There are limitations in the use of disability-adjusted life years (DALYs) as a formulation when dealing with events around the time of birth. The DALY can be extended by modeling a concept of gradual acquisition of life potential (ALP) based on two judgments: that an individual life acquires value as it acquires self-awareness and that it acquires additional value as it interacts with others. A mechanism is proposed to allow for the use of gradual ALP in DALY modeling.

In the standard DALY formulation, the ratio of YLL for a death at age 20 versus a death at birth is approximately one. ALP allows us to vary this ratio, and in particular we propose a variant that yields a value of about three for this number.