Forty-two percent (42%) of child deaths occur in the World Health Organisation Africa region (WHOAFRO) countries, and in 2019, a United Nations (UN) report showed that about 857,899 under-5 child deaths were recorded in Nigeria alone. 

Over the years, child mortality has been on a decline in some states in Nigeria, although some other states still record high rates which are above the national target. For example, in 2018, Kebbi, Jigawa and Sokoto states had the highest number of under-5 deaths, greatly exceeding the national target (see fig. 1), while Bayelsa and Ogun states had the least (NDHS, 2018). The North-western states in particular, have the highest rates of child (under-5) mortality in Nigeria (Fig. 2).

Research has shown that the main causes of under-5 mortality in Nigeria include; Neonatal disorders (22.9%), lower respiratory infections (19.4%), diarrhea (13.2%), malaria (13.9%), meningitis (5.45%), protein-energy malnutrition (2.8%), measles (2.5%), HIV/AIDS (2%), tuberculosis (1.4%), and other sexually transmitted infections (1.6%) (Statista, 2017). 

Although there has been remarkable progress in reducing child mortality globally, more child survival strategies need to be employed.

Figure 1: Under-5 mortality rate (per 1,000) in Nigeria NDHS, 2018 (Source: The MSDAT)
Figure 2: Under 5 mortality rates by geographical zones NDHS, 2018 (Source: The MSDAT)


What are Child Survival Strategies? 

Child survival strategies (CSS) are the various steps taken on behalf of children aged 0-5 by individuals and communities to reduce the risks and severity of adverse health conditions that these children are prone to (USAID, 2002). They are strategies that have been put in place by the United Nations Children Education Fund (UNICEF) to help combat the issue of child morbidity and mortality among under-5 children (UNICEF 2006).  

The strategies are seven in number and are are represented with the acronym “GOBIFFF”; meaning: 

1, Growth monitoring;

2, Oral rehydration; 

3, Breastfeeding; 

4, Immunization; 

5, Female education; 

6, Family planning; and 

7, Food fortification (UNICEF, 2006). 

1, Growth monitoring: This involves the routine measurements (weight, height etc) of a child to help detect abnormal growth. It is the process of following the growth rate of a child in comparison to the standard, in order to detect faltering early on and address it accordingly (Griffiths and Rosso, 2007). It is also used as a screening tool to diagnose nutritional, chronic systemic and endocrine disease at an early stage (Khadilkar et al., 2007). 

2, Oral rehydration: Diarrhoea has been observed to be the second leading cause of death and malnutrition in children under age 5, as it accounts for more than 500,000 deaths globally (GBD, 2017) and most also result from dehydration. Oral rehydration involves the administration of the oral rehydration solution (ORS) to replace lost ions and electrolytes in a body system to prevent dehydration (WHO, 2009). As observed in fig. 3, Nigeria had the highest number of child deaths due to diarrhoea in 2016. 

Figure 3: Number of child deaths in countries as a result of diarrhoea (Harriet et al., 2016) 

3. Breastfeeding: Under-nutrition in under-5 children causes an estimated 2.7 million child deaths annually, which is about 45% of all child deaths. Optimal breastfeeding, which is also known as exclusive breastfeeding (breastfeeding an infant from 0-6 months of life), has been observed to save the lives of over 820,000 under-5 children yearly (WHO, 2018). After 6 months of the infant’s life, complementary feeding can be combined with breastfeeding to help boost the nutrition of the child and further save lives. In 2016, about 24% of children below 6 months were exclusively breastfed. In addition, only 3 states (Osun, the FCT and Lagos states) in the country were above the target for exclusive breastfeeding as seen in fig 4 (MICS, 2016).

Figure 4: Percentage of children under 6 months who were exclusively breastfed in Nigeria (MICS, 2016). (Source: The MSDAT)

4, Immunization: This is a method of administering protective measures against infectious diseases in children (Tadesse et al., 2009). It is a core child survival strategy which is targeted at averting about 1.2 million child deaths every year (Malande et al., 2019). It is also a key strategy toward achieving the Sustainable Development Goal (SDG) number 3 (WHO, 2010). Despite the benefits associated with this child survival strategy, vaccine-preventable diseases (VPDs) are still a major cause of child illnesses and death in low and middle income countries (LMICs) such as Nigeria (GBD, 2016).  

Africa is observed to have the highest under-5 mortality rate in the entire world and this accounts for 40% of the total deaths in this under-5 age group (Wiysonge et al., 2012). Over the years, immunization programs in Africa have progressed; however, immunization coverage is still low for some of the recommended childhood vaccines. In Nigeria, only about 60% of children were fully immunized in the year 2020 (fig. 5) and this fell below the national target of 85%. Only 3 states (Jigawa, Adamawa and Kaduna) went above the national target and the lowest states were Benue, Akwa-Ibom and Edo with Bayelsa having the least percentage of 18.9%. 

Figure 5: Percentage of children immunized across various states in Nigeria (NHMIS, 2020). (source: The MSDAT)

5, Female education: Various researches have shown that female education has an impact on child survival and for a child born alive to die between its first and fifth birthday is still very pervasive in the LMICs (Adepoju et al., 2012; NDHS, 2013). In sub-Saharan Africa, mortality among under-5 children is still very high with a rate of 84 deaths in every 1000 live births in 2015 (UNDP, 2016) which confirms that half of the world’s childhood deaths take place in this region (Smith, 2010). These deaths have been linked to several factors, one of which is the education of the female (mother of the child) as research has shown.  

According to Nigeria’s Demographic and Health Survey (2018) (fig. 6), high (170) and low (56) child mortality was recorded among mothers with no education and those with tertiary education respectively. Also, the risk of childhood mortality among educated fathers and mothers is lower for those with no formal education (Yaya et al., 2017). 

Figure 6: Under-5 mortality rate (Per 1000) by mothers’ level of education (NDHS, 2018)

6, Food fortification: This is the deliberate addition of nutrients in food to meet the demands of increased intake requirements of under-5 children as it targets restoring nutrients lost through food processing (Ottaway, 2008; Meenakshi et al., 2010). It entails increasing nutrient intake in infants, which helps to mitigate micronutrient deficiency and poor growth in children after the period of exclusive breastfeeding (Mannar and Sankar, 2004). In 2020, Oyo, Kaduna and Nasarawa states had the highest number of underweight children (exceeding the national value) while Ekiti state had the least with 17.3, which is way below national value (fig. 7). 

Figure 7: Number of underweight under-5 children (per 1,000) across all Nigerian states (NHMIS, 2020).

7, Family planning: This is a deliberate action that entails controlling the timing and number of pregnancies in women (UNICEF, 1998). It has been observed that several morbidities and mortalities are associated when there is no adequate spacing in childbirth (<36 months interval) (Rustein et al., 2009). Nigeria has an under-5 mortality rate of 187 per a thousand live births, and this is very high as compared to the other developing countries of the world (UNICEF, 2013). From fig 8. Bayelsa state had the least prevalence of contraceptives, while Sokoto, Kaduna and the FCT had the highest rates. No state met the national target of 43%.

Figure 8: Prevalence of contraceptive use across all states in the country (NHMIS, 2020) (Source: MSDAT)

The Role Of Mothers 

In order to promote child survival in Nigeria and other countries of the world, mothers have various roles to play which include the following: 

1, Subscribing to the use of health facilities (for pregnant and nursing mothers) as this will afford them the knowledge needed to carry on in caring for themselves and the children after birth (Ayotunde et al., 2009); 

2, Exclusive breastfeeding (first 6 months) should be practiced after which complementary feeding can be incorporated alongside breastfeeding, to help improve the child’s nutrition and health, thereby enhancing  their survival (WHO, 2018). Breastfeeding should continue for up to two years or beyond. 

3, Continued education should be practiced, as this will increase their knowledge about other child survival strategies (including new insights and trends) and make them more observant and intentional about the child’s growth (Adewusi and Nwokocha, 2018);

4, Family planning should also be considered by all mothers. This will help space childbirth to give room for proper growth and development in a child before another is birthed, thereby enhancing survival in under-5 children (WHO, 2020). 

The Role Of Health Care Workers 

Community health care workers are the frontline workers who support healthcare programmes and as such, have a role to play in ensuring child survival strategies in the community and world at large. Their roles include the following: 

1, Identifying pregnant women and diagnosing existing and pregnancy-related conditions, promoting health through education, hence giving antenatal care (NPHCDA, 2011); 

2, Teaching women on health promotion through healthy lifestyles in pregnancy and also during postnatal period, and distributing commodities such as mosquito nets (NPHCDA, 2013). 

3, Facilitating birth and emergency preparedness for unexpected adverse events/complications that may occur in pregnancy or post-natal (FMoH, 2014); 

4, Ensuring they are well equipped for vaccination, dispensing micronutrient supplements and oral medications during postnatal periods (NPHCDA, 2011); 

5, Carrying out growth monitoring in children to observe their growth matrix and to detect anomalies as soon as possible (NPHCDA, 2013); 

6, Promoting breastfeeding and family planning programs amongst mothers by informing them of the importance and the benefits attached (CHPN, 2006). 

The Role Of The Government 

The government also has their role to play in supporting and ensuring that UNICEF’s child survival strategies reach its goal of reducing under-5 child morbidity and mortality across the globe. Their roles include: 

1, Provision and subsidization of vaccines for children under 5 so as to improve immunization coverage; 

2, Capacity development for all healthcare workers; 

3, Provision of funds for use in the health care sector or system; 

4, Provision and subsidization of food fortification supplements needed to enhance child survival; 

5, Provision of health care infrastructures and deployment of workers to serve the community or general public; 

6, Creation of awareness through flag-offs on the importance of breastfeeding, family planning and immunization (UNICEF, 2013).

Conclusion And Recommendation 

Child survival strategies are important in promoting child survival in under-5 children and as such should be duly employed by all so as to combat the menace of child death in all countries globally. Mothers, healthcare workers and governments should embrace their roles diligently so as to make these strategies reach their goal, and in turn help to achieve the Sustainable Development Goal (SDG) number 3 which is to “Ensure healthy lives and promote well-being for all at all ages”.


1, Adepoju, A.O., Akanni, O. and Falusi, A.O. 2012. Determinants of child mortality in rural Nigeria. World Rural Observ., 4(2): 38-45. 

2, Adewusi, O. and Nwokocha, E. E. 2018. Maternal education and child mortality in Nigeria. The Nigerian Journal of Sociology and Anthropology. 16(1): 111-130. 

3, Ayotunde, T., Obiyan, M., Agunbiade, M. and Faniyi, F. 2009. Maternal age at birth and under-5 mortalities in Nigeria. East African Journal of Public Health, 6(1): 11-14. 

4, Bello, A., Ibrahim, A.D., Abdullahi, M. and Lawal, B. 2015. Clinical symptoms of Human Rotavirus infection observed in children in Sokoto, Nigeria. Advances in Virology. 1(6).  

5, Community Health Practitioners Registration Board Nigeria, 2006. Curriculum of community health practitioners. 

6, Federal Ministry of Health, 2014. Task shifting and task sharing policy for essential healthcare services in Nigeria. Abuja. 

7, GBD 2016 Causes of death collaborators 2017. Global, regional and national age-sex specific mortality for 264 causes of death, 1980-2016: a systematic analysis for the global burden of disease study 2016. Lancet (London England), 390(10100), 1151-1210. 

8, Griffiths, M. and DelRosso, J. 2007. Growth monitoring and the promotion of healthy young child growth: Evidence of effectiveness and potential to prevent malnutrition. The Manoff group. Pp. 2-36.  

9, Harriet, U., Obinna, N., Oranusi, S. and John, O. 2016. Childhood diarrhoea in developing countries. Heliyon 6. 

10, Khadilkar, V.V., Khadilkar, A.V., Choudhury, P., Agarwal, V.E., Deepak, U.D. and Shah, N.K. 2007. Growth monitoring guidelines for children from birth to 18 years. Indian pediatr.44: 187-197. 

11, Malande, O.O., Munube, D., Afaayo, R.N., Annet, K., Bodo, B., Bakainaga, A., Ayebare, E., Njunwamukama, S., Mworozi, A.E., Muskoyi, M.A. 2019. Barriers to effective uptake and provision of immunization in Africa. PloS one vol. 14;2 e0212270.

12, Manar, M.G. and Sankar, R. 2004. Micronutrients fortification of food-rationale, application and impact. Indian J pediatr; 71: 997-1002. 

13, Meenakshi, J.V., Johnson, N.L., Manyong, V.M., Degroote, H., Javelosa, J. et al., 2010. How cost effective is biofortification in combating micronutrient malnutrition? An ex ante assessment. World dev; 38: 64-75. 

14, National Primary Health Care Development Agency, 2011. Handbook on essential maternal and newborn care for primary health care providers. 

15, National Primary Health Care Development Agency, 2013. Minimum standards for primary health care in Nigeria. NDHS. 2013. Nigeria Demographic and Health Survey.  

16, NDHS. 2018. Nigeria Demographic and Health Survey. 

17, NHMIS, 2020. Statistics of fully vaccinated children, and child under-5 mortality rate and underweight children. 

18, Ottaway, PB. 2008. Food fortification and supplementation: Technological, safety and regulatory aspects. Cambridge, Woodhead Publishing Ltd. 

19, Rustein, S., Ayad, M., Ren, R. and Hong, R. 2009. Changing health conditions and decline of infant and child mortality in Benin. Calverton, Maryland, USA. 

20, Smith, E.G. 2010. Maternal schooling and child mortality in Nigeria: The importance of the actual curriculum. Retrieved on 21/11/2017 at  

21, Tadesse, H., Deribew, A., Woldie, M. 2009. Explorative assessment of factors affecting child immunization in Africa. Arch Med Sci. 5(2); 233-40. 

22, The Lancet, 2005. The six leading causes of under-5 mortality in Africa.

23, UN, 2019. United Nation’s report on under-5 child mortality in Nigeria.  

24, UNDP 2016. Human Development Report. The rise of the South: Human progress in a diverse world, New York: United Nations Development Programme. 

25, UNICEF, 1998. The state of the world’s children. UNICEF Oxford University Press. Oxford. 

26, UNICEF, 2006. Progress for children: A report card on nutrition. Available from;  

27, UNICEF, 2013. The state of the world’s children and roles of various governments. UNICEF Oxford University Press. Oxford. 

28, USAID, 2002. Child survival and health programmes. USAID Washington DC. 

29, WHO, 2009. Stuart, M.C., Kouimtzi, M., Hill. S.R. (eds). WHO Model Formulary 2008. Pp. 349-351.  

30, WHO Library Cataloguing-in-Publication Data. World health statistics 2010. Available from:

31, WHO, 2018. Facts about breastfeeding as it promotes child survival.  https://www.who.facts/breastfeeding/2018

32, WHO, 2020. Family planning; A global handbook for providers.

33, Wiyesonge, C.S., Uthman, O.A., Ndumbe, P.M., Hussey, G.D. 2012. Individual and contextual factors associated with low childhood immunization coverage in sub-Saharan Africa. PloS one; vol 7,5 e37905. 

34, Yaya, S., Ekholuenetale, M., Godson, T., Vaibhave, S., Bishwajit, G., and Kadio, B. 2017. Prevalence and determinants of childhood mortality in Nigeria. BMC Public Health, 17;485, 1-7.