BMJ Open: first published as 10.1136/bmjopen-2021-050551 on 24 August 2021. Downloaded from http://bmjopen.bmj.com/ on August 24, 2021 at Sectoral & IT Resource CTR World Bank
 Open access                                                                                                                     Original research


                                    How many infants may have died in
                                    low-­income and middle-­income
                                    countries in 2020 due to the economic
                                    contraction accompanying the
                                    COVID-19 pandemic? Mortality
                                    projections based on forecasted declines
                                    in economic growth
                                    Gil Shapira  ‍ ‍, Damien de Walque  ‍ ‍, Jed Friedman  ‍ ‍



To cite: Shapira G, de Walque D,    ABSTRACT
Friedman J. How many infants                                                                         Strengths and limitations of this study
                                    Objectives  While COVID-19 has a relatively small direct
may have died in low-­ income       impact on infant mortality, the pandemic is expected to




                                                                                                                                                                                                                                           MC-C3-220. Protected by copyright.
and middle-­ income countries                                                                        ►► Our study links gross domestic product (GDP) per
                                    indirectly increase mortality of this vulnerable group in
in 2020 due to the economic                                                                             capita data to an especially large dataset of 5.2
                                    low-­income and middle-­  income countries through its
contraction accompanying                                                                                million retrospective birth histories reported in
the COVID-19 pandemic?              effects on the economy and health system performance.
                                                                                                        Demographic and Health Surveys conducted in
Mortality projections based         Previous studies projected indirect mortality by modelling
                                                                                                        many low-­ income and middle-­  income countries be-
on forecasted declines in           how hypothesised disruptions in health services will affect
                                                                                                        tween 1985 and 2018.
economic growth. BMJ Open           health outcomes. We provide alternative projections,
                                                                                                     ►► While previous projections of indirect COVID-19
2021;11:e050551. doi:10.1136/       relying on modelling the relationship between aggregate
bmjopen-2021-050551
                                                                                                        mortality have been based on assumptions regard-
                                    income shocks and mortality.
                                                                                                        ing the magnitude of health service disruptions,
►► Prepublication history and
                                    Design  We construct a sample of 5.2 million births by
                                                                                                        our estimates account for additional mechanisms,
additional supplemental material    pooling retrospective birth histories reported by women
                                                                                                        mainly increased household poverty.
for this paper are available        in Demographic and Health Surveys conducted in 83
                                                                                                     ►► Our estimates may represent a lower bound of the
online. To view these files,        low-­income and middle-­  income countries between 1985
                                                                                                        actual excess mortality if the current economic
please visit the journal online.    and 2018. We employ regression models with country-­
(http://​dx.​doi.o
                 ​ rg/​10.​1136/​
                                                                                                        downturn is accompanied by larger disruptions to
                                    specific fixed-­effects and flexible time trends to estimate
bmjopen-​2021-​050551).                                                                                 the provision of essential health services relative to
                                    the impact of gross domestic product per capita on infant
                                                                                                        previous downturns.
                                    mortality rate. We then use growth projections by the
Received 22 February 2021                                                                            ►► We estimate the short-­ term impact of GDP fluctu-
                                    International Monetary Fund to predict the effect of the
Accepted 02 August 2021                                                                                 ations on mortality while long-­   term implications
                                    economic downturn in 2020 on infant mortality.
                                                                                                        for mortality and other adverse outcomes may also
                                    Results  We estimate 267 208 (95% CI 112 000 to 422
                                                                                                        arise.
                                    415) excess infant deaths in 128 countries, corresponding
                                                                                                     ►► The analysis ascribes the difference between
                                    to a 6.8% (95% CI 2.8% to 10.7%) increase in the total
                                                                                                        October 2019 and October 2020 economic growth
                                    number of infant deaths expected in 2020.
                                                                                                        projections for 2020 solely to the pandemic, even
                                    Conclusions  The findings underscore the vulnerability
                                                                                                        though some countries have also experienced other
                                    of infants to the negative income shocks such as those
                                                                                                        shocks, such as natural disasters or political crises
                                    imposed by the COVID-19 pandemic. While efforts towards
                                                                                                        that may affect national income levels.
                                    prevention and treatment of COVID-19 remain paramount,
© Author(s) (or their
                                    the global community should also strengthen social safety
employer(s)) 2021. Re-­use
permitted under CC BY-­ NC. No      nets and assure continuity of essential health services.
                                                                                                    may be substantial. Health and social poli-
commercial re-­ use. See rights
and permissions. Published by                                                                       cies should not lose sight of excess indirect
BMJ.                                INTRODUCTION                                                    mortality caused by such factors as the inter-
Development Research Group,         Reducing morality risk in the wake of the                       ruption of essential health services and the
World Bank, Washington,             COVID-19 pandemic is a paramount public                         general economic downturn brought on by
Columbia, USA                       concern. While direct mortality risk as a                       the pandemic. This study attempts to quan-
 Correspondence to                  result of COVID-19 infection has garnered                       tify the expected indirect mortality over the
 Dr Gil Shapira;                    the majority of attention in global media                       pandemic period for one especially vulner-
                     ​ rg
​gshapira@​worldbank.o              and policy discussions, indirect mortality                      able subpopulation—infants—by modelling

                                            Shapira G, et al. BMJ Open 2021;11:e050551. doi:10.1136/bmjopen-2021-050551                                          1
                                                                                                                                                BMJ Open: first published as 10.1136/bmjopen-2021-050551 on 24 August 2021. Downloaded from http://bmjopen.bmj.com/ on August 24, 2021 at Sectoral & IT Resource CTR World Bank
Open access

the impact of projected economic decline on the likeli-         middle-­income countries between 1985 and 2018. The
hood of infant survival.                                        surveys used in the analysis are listed in online supple-
   Studies from diverse settings find negligible direct         mental appendix table A1. The combined sample totals
mortality rates for children and infants due to COVID-          5.2 million births, of which 27% and 55% are from low-­
19.1 However, stringent containment measures and                income and lower-­         income countries. Over the full
                                                                                    middle-­
the ensuing economic downturn, as well as the need to           period of analysis, the sample’s infant mortality rate per
reallocate health system resources towards pandemic                                                  income, lower-­
                                                                1000 births is 85, 61 and 37 for low-­             middle-­
response, have influenced many social determinants of           income and upper-­  middle-­ income countries, respectively.
mortality such as the ability to afford nutritious foods and      We estimate the relation between aggregate income
to access essential healthcare. Unlike economic crises in       change and infant mortality with the following framework:
high-­income countries, which appear to lower mortality,2
                                                                	‍         Dict = αc + β logGDPct + γ1c tct + γ2c t2         3
                                                                                                                    ct + γ3c tct + εict ‍
economic crises in low-­      income countries generally
increase mortality among vulnerable groups, namely
                                                                         is a binary indicator taking the value 1 if child ‍
                                                                   ‍Dict ‍                                                      i ‍ in
young children and the elderly. Earlier studies have docu-
mented a robust relationship between short-­    term fluctua-   country ‍     c‍died in the first 12 months of life during year ‍    t‍.
tion in aggregate income and all-­  cause infant mortality in   logGDP
                                                                ‍           ‍is the natural logarithm    of per  capita GDP and  ‍
                                                                                                                                 ε  iact ‍
low-­income and middle-­   income countries.3–8                 is the error term. The ‍α‍ and γ coefficients identify country-­
   At the very start of the COVID-19 pandemic, model-           specific fixed effects and a country-­          specific cubic time
ling exercises predicted that the interruption of essen-        trend, respectively. SEs are clustered at the country level;
                                                                β ‍is the coefficient of interest, describing the relationship
                                                                ‍
tial health services will be severe9–1412 and perhaps the
world will experience 250       000 to 1.15   million young     between aggregate income shocks and infant mortality.
child deaths15 in the first 6     months of the pandemic.       We estimate this semi-­         elasticity of infant mortality to
Recent studies indicate that barriers to access essential       aggregate income decline separately by country income
healthcare in low-­  income and middle-­   income countries     level, as classified by the World Bank 2020 income groups,




                                                                                                                                                                                                                      MC-C3-220. Protected by copyright.
are not just a theoretical concern documenting, for             as well as overall. Low-­     income economies are defined by
example, disruptions in immunisation services in Paki-          a gross national income (GNI) per capita of <US$1035
stan and Sierra Leone16 17 and access to primary care           in 2019. Lower middle-­         income economies are defined
in sub-­ Saharan Africa.18 19 At the same time, the global      by a GNI between US$1036 and US$4045 and the range
economy is expected to contract 4.9% in the first year          for upper-­             income economies is between US$4046
                                                                                 middle-­
of the pandemic20 and the global poverty headcount is           and US$12 535. To explore the robustness of the findings,
projected to increase by 120 million people.21 Based            both we and Baird et al5 find appreciably similar results
on historical data, this economic decline is likely to be       with linear or quadratic time trends, as well as alternative
associated with higher mortality in excess of COVID-19          recall periods for births (5 or 15 years as opposed to the
fatalities,22 especially in low-­
                                income and middle-­  income     default 10 years).
economies, and will create food insecurity23 and lower the         As a projection of the aggregate income shock in
affordability among vulnerable households of key goods          each country, we compare growth predictions for the
and services necessary for child survival.                      same calendar period made before and then during the
   In this study, we estimate the impact of the economic        pandemic. Specifically, we use the IMF WEO 2020 growth
downturn on infant mortality by modelling the relation-         rates projected in October 2019 and in October 2020. We
ship between GDP fluctuations and infant mortality,             define the difference between the two projections as the
following the approach of Baird et al.5 We link GDP per         growth shortfall that is likely attributed to the pandemic
capita data to 5.2 million retrospective birth histories        and the ensuing economic crisis. Between October
reported in 83 Demographic and Health Surveys (DHS)             2019 and October 2020, the IMF revised downwards the
conducted in low-­   income and middle-­   income countries     growth projections for all countries. The average short-
between 1985 and 2017. Then, we use growth projections          fall for low-­    income and middle-­   income countries is 9.3%.
by International Monetary Fund (IMF) World Economic             The average projected shortfall in low-­          income countries,
Outlook (WEO) to predict the effect of the economic             5.9%, is less than half of the projected average shortfall in
downturn in 2020 on infant mortality.                           upper-­middle-­income countries, 12.5%.
                                                                   To calculate the number of excess infant deaths that
                                                                were likely caused by the pandemic in each country,
DATA AND METHODS                                                we multiply the projected growth shortfalls with the β
To estimate the impact of changes in aggregate income           coefficient from the regression specification above. We
on infant mortality, we rely on two sources of data. Data       then multiply by the projected number of births in each
on GDP per capita is taken from the World Development           country, taken from the United Nation’s World Popu-
Indicators. We use values adjusted for purchasing power         lation Prospects 2019. The total number of births are
parity, corresponding to 2011 US dollars. Data on infant        projected for the 5-­     year period 2015–2020 and we assume
mortality are constructed from retrospective birth history      equal proportion of births for each year (the projections
reports in all DHS conducted in 83 low-­     income and         are available at ​population.​un.​org/​wpp).

2                                                                 Shapira G, et al. BMJ Open 2021;11:e050551. doi:10.1136/bmjopen-2021-050551
                                                                                                                                                      BMJ Open: first published as 10.1136/bmjopen-2021-050551 on 24 August 2021. Downloaded from http://bmjopen.bmj.com/ on August 24, 2021 at Sectoral & IT Resource CTR World Bank
                                                                                                                                  Open access

 Table 1  Estimated relationship between aggregate income shocks and infant mortality rate per 1000 children, by World Bank
 country income groups
 Low-­income                  Lower-­middle-­income                     Upper-­middle-­income                 Low-­income and middle-­income
 countries                    countries                                 countries                             countries
 −47.85***                    −23.73***                                 −16.08***                             −23.12***
 (17.71)                      (5.50)                                    (6.80)                                (9.38)
 Overall number of observed births is 5 273 350. The table presents coefficient estimates from regressions of infant mortality log per capita
 GDP with time trends and country fixed effects. SEs are presented in parentheses. There are four income groupings for countries; the country
 income groups follow the World Bank classification for fiscal year 2021.
 Source: authors’ estimation using data from Demographic and Health Surveys and World Development Indicators.
 *P<0.10, **p<0.05, ***p<0.01.



Patient and public involvement                                                 in the lower-­middle-­income countries group and because
The study presents analysis of secondary data. There was                       the IMF projects larger growth shortfalls in that group.
no patient and public involvement.                                             It is worth noting than more than a third of the excess
                                                                               infant mortality is projected to be in India (99 642). India
                                                                               has the highest number of annual births (24 238 000) as
RESULTS                                                                        well as a particularly large projected economic shortfall of
Estimation of the GDP-mortality relationship                                   −17.3%. Because of this, South Asia is the region with the
The regression coefficient estimates are presented in                          highest expected excess infant mortality, although there
table 1. A 1% decrease in GDP per capita is associated                         are only eight countries included in the analysis. Nigeria
with a 0.23 increase in infant mortality per 1000 chil-




                                                                                                                                                                                                                            MC-C3-220. Protected by copyright.
dren born in low-­  income and middle-­   income countries.
These estimates vary substantially by income group. A 1%                        Table 2  Projected excess infant deaths with 95% CIs, by
decrease in per capita GDP is associated with increases of                      World Bank country income groups and regions
0.48, 0.24 and 0.16 in infant mortality per 1000 children                                           Estimate 95% CI                   Countries
born in low-­  income, lower-­ middle-­ income and upper-­
middle-­income countries, respectively.                                         Total               267 208      112 000 to 422 415   128
  Our estimate for the relationship between GDP and                             By income group
infant mortality is significantly lower than the estimate                        Low-­income        65 628      18 013 to 113 241     29
presented in the study by Baird et al, using the same                             economies
specification.5 This previous analysis estimated that a                          Lower-­middle-­ 158 638        86 646 to 230 628     46
1% decrease in GDP per capita is associated with a 0.40                           income
increase in infant mortality per 1000 children born in                            economies
low-­
    income and middle-­    income countries. Two things                          Upper-­middle-­    42 942      7340 to 78 544        53
might drive this difference. First, we have a different                           income
                                                                                  economies
composition of countries given that more DHS datasets
are available. Our analysis includes 83 countries relative                      By region
to 59 in the earlier paper. Second, resiliency to income                         Sub-­Saharan       82 239      29 198 to 135 280     48
shocks may have improved over time through increased                              Africa
household incomes and more developed health systems.                             East Asia and      32 537      12 899 to 52 174      19
                                                                                  Pacific
Projection of excess infant mortality in 2020                                    Europe and          7962       2372 to 13 553        20
In table 2, we report the estimated excess infant mortality                       Central Asia
in 128 low-­ income and middle-­    income countries, along                      Latin America      17 202      3628 to 30 776        23
with 95% CI around the estimate. The results by income                            and the
group and region presented in table 2 are aggregations of                         Caribbean
the country-­ level projections presented in online supple-                      Middle East        14 127      4067 to 24 187        10
mental appendix table A2. In total, we estimate 267      208                      and North
(112 000–422 415) excess infant deaths in lower-­    income                       Africa
and middle-­  income countries due to the growth shortfall                       South Asia        113 141      59 836 to 166 446      8
in 2020. Most of the excess mortality is estimated to occur                     The definitions of income groups and regions are based on the
in the 46 lower-­  middle-­income countries, even though                        World Bank country group categorisation for the 2021 fiscal
the income mortality semi-­                     income coun-
                              elasticity in low-­                               year.
tries is almost twice the size of that in lower-­    middle-­                   Source: authors’ projections based on estimated parameters
income countries. This is explained both by the fact that                       presented in table 1 and data from International Monetary Fund
                                                                                World Economic Outlook and World Population Prospects.
there are more countries and more populous countries

Shapira G, et al. BMJ Open 2021;11:e050551. doi:10.1136/bmjopen-2021-050551                                                                       3
                                                                                                                                             BMJ Open: first published as 10.1136/bmjopen-2021-050551 on 24 August 2021. Downloaded from http://bmjopen.bmj.com/ on August 24, 2021 at Sectoral & IT Resource CTR World Bank
Open access

and China are a distant second and third with projected        a lower bound of actual indirect mortality. On the other
excess infant deaths of 11 904 and 10 835.                     hand, the projections reported in this paper ascribe the
  To benchmark our projections of excess infant deaths,        difference between the WEO October 2019 and October
we assess the percentage increase in infant mortality these    2020 economic growth projections for 2020 solely to the
additional deaths represent. To that end, we calculate the     pandemic, even though some countries have also experi-
expected infant mortality in the absence of the pandemic       enced other shocks, such as natural disasters or political
for the 128 countries. According to the World Bank’s           crises.
World Development Indicators, estimated infant mortality          Regarding limitations of the analysis, one refinement
rates in low-­income, lower-­         income and upper-­
                               middle-­                        of our estimation approach would consider the rele-
middle-­income countries were 48, 37 and 11 deaths per         vant expenditure categories that directly determine the
1000 live births, respectively in 2019. We multiply these      production of child health, rather than overall expendi-
rates by the annual number of births in each country to        ture as captured in GDP. Relevant expenditure categories
forecast a total of 3 953 466 deaths. Assuming that infant     include public health sector spending, private spending
mortality rate in 2020 would have been similar to that         on health and nutrition, foreign assistance in the form
in 2019 if the COVID-19 outbreak has not occurred,             of health aid and public and private spending on related
the excess deaths we project correspond to an increase         sectors and services such as water and sanitation. It is
of 6.8% (95% CI 2.8% to 10.7%) in the total number of          these components of GDP that are more directly tied to
expected infant deaths.                                        child survival and would likely exhibit a more predictive
                                                               relationship to infant mortality than overall GDP exhibits.
                                                               Unfortunately, these more granular data do not exist in
DISCUSSION                                                     a systematic and standardised form for the countries and
In this study, we have assessed the potential impact of        time periods considered, nor are there standard future
the 2020 economic downturn caused by the COVID-19              projections of such components. Therefore, we follow
pandemic on infant mortality—we estimate almost                the existent literature and explore the relation between




                                                                                                                                                                                                                   MC-C3-220. Protected by copyright.
270  000 excess infant deaths in the 12 months following       a widespread summary measures of national economic
the start of the pandemic. A useful comparison point to        output, GDP, and infant survival.
this estimate is the 28         000 excess infant deaths
                          000–50                                  An extension of our approach may also consider country
estimated for Africa after the financial crisis in 2009.7      characteristics that likely mediate the GDP-­mortality rela-
Our Africa estimate in 2020 is 82 239 (95% CI 37 858 to        tion, including measures of economic inequality. Infant
126 620) infant deaths. This higher projection reflects        mortality in more unequal countries is likely more vulner-
the larger estimated GDP shortfalls. Several mechanisms        able to economic contractions. However, here again, we
are likely driving this increase in mortality among chil-      do not have the necessary annual data to easily include
dren 0–1 year of age: impoverishment at the household          a summary inequality measure such as the Gini coeffi-
level will lead to worse nutrition and care practices for      cient within our estimation framework. The DHS allow us
infants and reduced ability to access health services,         to construct annual birth and mortality indicators from
while the economic crisis might also affect the supply         retrospective reports of fertility yet do not include per
and quality of services offered by the health systems.19 It    capita consumption or wealth status for the same years.
is difficult to compare our estimates with other projec-       Standard cross-­ country datasets such as PovCalNet (​
tions focusing on health system disruption as the main         iresearch.​worldbank.​org/​PovcalNet/​index.​htm) update
driver as the methodology, the age ranges and the time         the national Gini coefficient only on a sporadic basis. For
period are different. The most comparable study, with a        example, the Gini estimate for India is only updated for
focus on child mortality, predicts 253 500–1 157 000 addi-     the years 1987, 1993, 2004, 2009, and 2011.
tional under-5 child deaths over the first 6 months of the        Another limitation of our analysis is that it relies on
pandemic, depending on the scenario severity.15                retrospective birth histories in DHS. In the absence of
   Our estimates of excess infant mortality are not addi-      comprehensive and robust vital registration statistics in
tional to previous projections but serve as an alternative.    most of the countries included in this analysis, this is likely
Our reduced form approach yields estimates that already        the most comprehensive data source available. However,
incorporate at least some consequences of reduced util-        such household survey data can be affected by recall bias,
isation of health services, that is, those reductions that     especially for birth and deaths occurring long before the
have historically arose during severe economic down-           survey date. For this reason, we have explored the stability
turns. Our estimates also directly account for other           of estimates to alternative birth recall periods and find
mechanisms, mainly increased poverty. As past economic         appreciably similar results. Another limitation is that we
crises were not driven by a pandemic, it is possible that      only consider the short-­ term impact of GDP fluctuations
the world will experience a higher indirect mortality          on mortality while long-­   term consequences might also
shock than implied by the historic income-­ mortality semi-­   exist. Long-­term impacts on the number of infant deaths
elasticity if the current economic downturn is accompa-        could also occur through changes in fertility behaviour
nied by more severe disruptions to the supply of effective     but should not affect our projections for 2020. Although
health services. Therefore, our projections may provide        COVID-19 was first detected in the end of 2019, the

4                                                              Shapira G, et al. BMJ Open 2021;11:e050551. doi:10.1136/bmjopen-2021-050551
                                                                                                                                                                          BMJ Open: first published as 10.1136/bmjopen-2021-050551 on 24 August 2021. Downloaded from http://bmjopen.bmj.com/ on August 24, 2021 at Sectoral & IT Resource CTR World Bank
                                                                                                                                              Open access

outbreak was declared a pandemic only in March 2020. If                       consequences of the pandemic and related lockdown
there were impacts on fertility, they would impact births                     policies.
and infant mortality in 2021. Finally, economic contrac-
tions in high-­ income countries might reduce foreign aid                     Acknowledgements  We gratefully acknowledge the excellent support provided
                                                                              by Salome Drouard as a research assistant. The findings, interpretations and
to lower-­ income countries which in turn can increase                        conclusions expressed in this paper are entirely those of the authors and do not
mortality.24 If declining aid affects future GDP, our model                   necessarily represent the views of the World Bank, its executive directors, of the
does not account for such mechanisms as we assume that                        governments of the countries they represent.
a country’s infant mortality rate is only affected by its                     Contributors  The study and the methodology were conceived by all authors.
(own) contemporaneous GDP.                                                    GS conducted the formal analysis. GS and JF validated the results. All authors
   Regarding the reported CIs for projected excess                            collaborated on writing the paper.
infant deaths in table 2, note that these bounds may be                       Funding  The authors have not declared a specific grant for this research from any
                                                                              funding agency in the public, commercial or not-­   profit sectors.
                                                                                                                              for-­
regarded as conservative. This is because we first apply
the 5th percentile lower bound and then the 95th percen-                      Competing interests  None declared.
tile upper bound estimate of the mortality semi-­     elasticity              Patient consent for publication  Not required.
to the projected growth contractions for all countries in                     Ethics approval  Ethics approval was not sought as the study presents results of
order to estimate the bounds. This exercise implicitly                        an analysis of secondary data and does not involve human participants.
imposes a perfect correlation of semi-­     elasticities across               Provenance and peer review  Not commissioned; externally peer reviewed.
countries. If instead, each country receives its own inde-                    Data availability statement  Data may be obtained from a third party and are not
pendent draw from the distribution of semi-­        elasticities              publicly available.
then there will be significantly tighter confidence bounds,                   Supplemental material  This content has been supplied by the author(s). It has
at least in expectation.                                                      not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been
   On the other hand, there may also be forecast error                        peer-­reviewed. Any opinions or recommendations discussed are solely those
                                                                              of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and
in either the country-­  level economic growth projections                    responsibility arising from any reliance placed on the content. Where the content
or in the projections of number of births. These poten-




                                                                                                                                                                                                                                                MC-C3-220. Protected by copyright.
                                                                              includes any translated material, BMJ does not warrant the accuracy and reliability
tial errors are not directly modelled. Previous literature                    of the translations (including but not limited to local regulations, clinical guidelines,
suggests these forecast errors have an expected mean                          terminology, drug names and drug dosages), and is not responsible for any error
                                                                              and/or omissions arising from translation and adaptation or otherwise.
of zero, with most deviations from forecast on the order
                                                                              Open access  This is an open access article distributed in accordance with the
of ±1 percentage point of economic growth or ±3% of
                                                                              Creative Commons Attribution Non Commercial (CC BY-­      NC 4.0) license, which
total births.2526 To explore further the role of uncer-                       permits others to distribute, remix, adapt, build upon this work non-­ commercially,
tainty in economic and demographic projections, we                            and license their derivative works on different terms, provided the original work is
consider Monte Carlo simulations that model country-­                         properly cited, appropriate credit is given, any changes made indicated, and the use
                                                                              is non-­commercial. See: http://​creativecommons.​org/​licenses/​by-​nc/​4.​0/.
specific growth and birth projections with a slightly larger
anticipated degree of error. Specifically, we simulate                        ORCID iDs
a draw for each country from growth projections that                          Gil Shapira http://​orcid.​org/​0000-​0002-​1138-​7269
are uniformly distributed around the projection at ±1.5                       Damien de Walque http://​orcid.​org/​0000-​0003-​1592-​7602
                                                                              Jed Friedman http://​orcid.​org/​0000-​0002-​6763-​5890
percentage points and draws for the birth projection
that are uniformly distributed around the projection at
±4%. After 10 000 simulations, we obtain a 95% CI of total
excess deaths to be (251 588 to 283 106), substantially
                                                                              REFERENCES
narrower than the reported CI of (112 000 to 422 415).                        	 1	 Levin A, Meyerowitz-­  Katz G, Owusu-­    Boaitey N. Assessing the age
This suggests that uncertainty in the true value of the                            specificity of infection fatality rates for COVID-19: systematic review,
growth-­ IMR semi-­ elasticity is the most influential param-                      meta-­ analysis, and public policy implications. Eur J Epidemiol
                                                                                   2020:1–16.
eter driving uncertainty in the projected total number of                     	 2	 Ruhm CJ. Health effects of economic crises. Health Econ 2016;25
indirect infant deaths.                                                            Suppl 2:6–24.
                                                                              	 3	 Pritchett L, Summers LH. Wealthier is healthier. J Hum Resour
   Regardless of the exact number of projected deaths,                             1996;31:841–68.
the large number of excess infant deaths estimated in                         	 4	 Bhalotra S. Fatal fluctuations? Cyclicality in infant mortality in India. J
                                                                                   Dev Econ 2010;93:7–19.
our analysis underscores the vulnerability of this age                        	 5	 Baird S, Friedman J, Schady N. Aggregate income shocks and infant
group to negative aggregate income shocks such as                                  mortality in the developing world. Rev Econ Stat 2011;93:847–56.
those induced by the COVID-19 pandemic. While we                              	 6	 Cruces G, Glüzmann P, Calva LFL, López LF. Economic crises,
                                                                                   maternal and infant mortality, low birth weight and enrollment rates:
focused on the 0–1 age group, our estimates are sugges-                            evidence from Argentina’s downturns. World Dev 2012;40:303–14.
tive of other vulnerabilities not directly attributable to                    	 7	 Friedman J, Schady N. How many infants likely died in Africa
                                                                                   as a result of the 2008-2009 global financial crisis? Health Econ
COVID-19 among other segments of the population                                    2013;22:611–22.
such as children aged 1–5 years, pregnant women and                           	 8	 Maruthappu M, Watson RA, Watkins J, et al. Effects of economic
the elderly. As countries, health systems and the wider                            downturns on child mortality: a global economic analysis,
                                                                                   1981-2010. BMJ Glob Health 2017;2:e000157. doi:10.1136/
global community continue efforts to prevent and treat                             bmjgh-2016-000157
COVID-19, we should also consider resources to stabi-                         	 9	 Abbas K, Procter SR, van Zandvoort K, et al. Routine childhood
                                                                                   immunisation during the COVID-19 pandemic in Africa: a benefit-­
lise health systems and strengthen social safety nets                              risk analysis of health benefits versus excess risk of SARS-­  CoV-2
in order to mitigate the human, social and economic                                infection. Lancet Glob Health 2020;8:e1264–72.


Shapira G, et al. BMJ Open 2021;11:e050551. doi:10.1136/bmjopen-2021-050551                                                                                           5
                                                                                                                                                               BMJ Open: first published as 10.1136/bmjopen-2021-050551 on 24 August 2021. Downloaded from http://bmjopen.bmj.com/ on August 24, 2021 at Sectoral & IT Resource CTR World Bank
 Open access

	10	 Hogan AB, Jewell BL, Sherrard-­   Smith E, et al. Potential impact of the   	18	 Siedner MJ, Kraemer JD, Meyer MJ, et al. Access to primary
     COVID-19 pandemic on HIV, tuberculosis, and malaria in low-­     income          healthcare during lockdown measures for COVID-19 in rural
     and middle-­ income countries: a modelling study. Lancet Glob Health             South Africa: an interrupted time series analysis. BMJ Open
     2020;8:e1132–41.                                                                 2020;10:e043763.
	11	 Jewell BL, Mudimu E, Stover J, et al. Potential effects of disruption to    	19	 Shapira G, Ahmed T, Drouard SHP, et al. Disruptions in maternal and
     HIV programmes in sub-­  Saharan Africa caused by COVID-19: results              child health service utilization during COVID-19: analysis from eight
     from multiple mathematical models. Lancet HIV 2020;7:e629–40.                    sub-­Saharan African countries. Health Policy Plan 2021. doi:10.1093/
	12	 Sherrard-­Smith E, Hogan AB, Hamlet A, et al. The potential public               heapol/czab064. [Epub ahead of print: 19 Jun 2021].
     health consequences of COVID-19 on malaria in Africa. Nat Med               	20	 International Monetary Fund. World economic outlook, October
     2020;26:1411–6.                                                                  2020: a long and difficult ascent, 2020.
	13	 World Health Organization. Pulse survey on continuity of essential          	21	 Lakner C, Yonzandaniel N, Mahlerr G, et al. Updated estimates of the
     health services during the COVID-19 pandemic, 2020.                              impact of COVID-19 on global poverty: looking back at 2020 and the
	14	 Kotlar B, Gerson E, Petrillo S, et al. The impact of the COVID-19                outlook for 2021, 2021.
     pandemic on maternal and perinatal health: a scoping review.                	22	 Doerr S, Hofmann B. The recession-­    mortality nexus and COVID-19.
     Reprod Health 2021;18:10.                                                        Bank of International Settlements, 2020.
	15	 Roberton T, Carter ED, Chou VB, et al. Early estimates of the indirect      	23	 Egger D, Miguel E, Warren SS, et al. Falling living standards during
     effects of the COVID-19 pandemic on maternal and child mortality in              the COVID-19 crisis: quantitative evidence from nine developing
     low-­income and middle-­ income countries: a modelling study. Lancet             countries. Sci Adv 2021;7. doi:10.1126/sciadv.abe0997. [Epub ahead
     Glob Health 2020;8:e901–8.                                                       of print: 05 Feb 2021].
	16	 Chandir S, Siddiqi DA, Mehmood M, et al. Impact of COVID-19                 	24	 Kabir M, Saqib MAN, Zaid M, et al. COVID-19, economic impact and
     pandemic response on uptake of routine immunizations in Sindh,                   child mortality: a global concern. Clin Nutr 2020;39:2322–3.
     Pakistan: an analysis of provincial electronic immunization registry        	25	 Eicher TS, Kuenzel DJ, Papageorgiou C, et al. Forecasts in times of
     data. Vaccine. 2020;38:7146–55.                                                  crises. Int J Forecast 2019;35:1143–59.
	17	 Buonsenso D, Cinicola B, Kallon MN, et al. Child healthcare                 	26	 Nico Keilman. Data quality and accuracy of United
     and immunizations in sub-­  Saharan Africa during the COVID-19                   Nations population projections. Demography;55:149–64.
     pandemic. Front Pediatr 2020;8:517.                                              doi:10.1080/00324720127686




                                                                                                                                                                                                                                     MC-C3-220. Protected by copyright.




6                                                                                Shapira G, et al. BMJ Open 2021;11:e050551. doi:10.1136/bmjopen-2021-050551
                                    BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance
Supplemental material                      placed on this supplemental material which has been supplied by the author(s)                          BMJ Open




                            Appendix Table A1: Demographic and Health Surveys datasets used in the analysis
                        Low-income                        Lower-middle income                      Upper-middle income
           Afghanistan 2015                      Angola 2016                               Albania 2009, 2018
           Benin 1996, 2001, 2006, 2012, 2018    Bangladesh 1994, 1997, 2000, 2004,        Armenia 2000, 2005, 2010, 2016
           Burkina Faso 1993, 1999, 2003, 2010           2007, 2011, 2014                  Azerbaijan 2006
           Burundi 1987, 2011, 2017              Bolivia 1989, 1994, 1998, 2004, 2008      Brazil 1986, 1992, 1996
           Central African Republic 1995         Cambodia 2000, 2006, 2011, 2014           Colombia 1986, 1990, 1995, 2000,
           DRC 2007, 2014                        Cameroon 1991, 1998, 2004, 2011, 2018             2005, 2010, 2016
           Ethiopia 2000, 2005, 2011, 2016       Comoros 1996, 2012                        Dominican Republic 1986, 1991,
           Gambia 2013                           Republic of Congo 2005, 2012                      1996, 1999, 2002, 2007, 2013
           Guinea 1999, 2005, 2012, 2018         Cote d’Ivoire 1994, 1999, 2012            Ecuador 1987
           Haiti 1995, 2000, 2006, 2012, 2017    Egypt 1989, 1993, 1996, 2003, 2005,       Gabon 2001, 2012
           Liberia 2007, 2013                            2008, 2014                        Guatemala 1987, 1995, 1999, 2015
           Madagascar 1992, 1997, 2004, 2009     El Salvador 1985                          Guyana 2009
           Malawi 1992, 2000, 2005, 2010, 2016 Eswatini 2007                               Jordan 1990, 1997, 2002, 2007, 2012,
           Mali 1987, 1996, 2001, 2006, 2013,    Ghana 1988, 1994, 2003, 2008, 2014                2018
                   2018                          Honduras 2006, 2012                       Kazakhstan 1995, 1999
           Mozambique 1997, 2004, 2011, 2015     India 1993, 1999, 2006, 2016              Maldives 2009, 2017
           Nepal 1997, 2001, 2006, 2011, 2017    Indonesia 1987, 1991, 1994, 1997, 2003,   Mexico 1987
           Niger 1992, 1998, 2006, 2012                  2007, 2012, 2017                  Namibia 1992, 2000, 2007, 2013
           Rwanda 1992, 2000, 2008, 2011, 2015 Kenya 1989, 1993, 1998, 2003, 2009,         Paraguay 1990
           Sierra Leone 2008, 2013                       2014                              Peru 1986, 1992, 1996, 2000, 2004-
           Tajikistan 2012, 2017                 Kyrgyz Republic 1997, 2012                        2012*
           Tanzania 1999, 2005, 2012, 2016       Lesotho 2005, 2010, 2014
           Togo 1988, 1998, 2014                 Moldova 2005
           Uganda 1989, 1995, 2001, 2006         Morocco1987, 1992, 2004
           Yemen 1992, 2013                      Myanmar 2016
                                                 Nicaragua 1998, 2001
                                                 Nigeria 1990, 2003, 2008, 2013, 2018
                                                 Pakistan 1991, 2007, 2013, 2018
                                                 Papua New Guinea 2018
                                                 Philippines 1993, 1998, 2003, 2008, 2013,
                                                         2017
                                                 Sao Tome and Principe 2009
                                                 Senegal 1986, 1993, 1997, 2011, 2012-
                                                         2018*
                                                 Sudan 1990
                                                 Timor Leste 2010, 2016
                                                 Tunisia 1988
                                                 Ukraine 2007
                                                 Uzbekistan 1996
                                                 Vietnam 1997, 2002
                                                 Zambia 1992, 1997, 2002, 2007, 2014,
                                                         2018
                                                 Zimbabwe 1989, 1994, 1999, 2006, 2011,
                                                         2015
                   Notes: The years denote the timing of survey implementation in each country. Some surveys spanned over more
                   than one calendar year. In these cases, the last year of the survey is indicated. For the analysis, retrospective birth
                   histories are used to create birth and infant mortality data for the 11 years preceding each survey.
                   * Senegal and Peru had special continuous surveys. Peru had annual survey between 2004 and 2012 and Senegal
                   completed annual surveys between 2012 to 2018.




                                                                               Shapira G, et al. BMJ Open 2021; 11:e050551. doi: 10.1136/bmjopen-2021-050551
                                          BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance
Supplemental material                                placed on this supplemental material which has been supplied by the author(s)                                                              BMJ Open




                            Appendix Table A2: Projections of growth shortfall and excess infant mortality in lower- and middle-income countries
                                                                   Number of          WEO projections of 2020 growth c                Excess mortality projection
                                                                  annual birth       October        October
                                                                  2015-2020 (in        2019           2020         Growth                     95% lower 95% higher
                                Country               Region a    thousands) b      projection     projection      Shortfall     estimate       bound          bound
                   Panel A: Lower Income Economies a
                   Afghanistan                          SAR           1205              3.5            -5.0           -8.5         4888          1342           8434
                   Benin                                AFR            413              6.7            2.0            -4.7          930          255            1604
                   Burkina Faso                         AFR            745              6.0            -2.0           -8.0         2852          783            4920
                   Burundi                              AFR            433              0.5            -3.2           -3.7          775          213            1338
                   Central African Republic             AFR            165              5.0            -1.0           -5.9          468          128             807
                   Chad                                 AFR            648              5.4            -0.7           -6.1         1894          520            3267
                   Congo, Dem. Rep.                     AFR           3434              3.9            -2.2           -6.0         9925          2724          17126
                   Eritrea                              AFR            106              3.9            -0.6           -4.5          226           62             391
                   Ethiopia                             AFR           3514              7.2            1.9            -5.3         8832          2424          15240
                   Gambia, The                          AFR             87              6.4            -1.8           -8.2          343           94             591
                   Guinea                               AFR            449              6.0            1.4            -4.5          970          266            1673
                   Guinea-Bissau                        AFR             66              4.9            -2.9           -7.8          245           67             422
                   Haiti                                LAC            271              1.2            -4.0           -5.2          674          185            1164
                   Liberia                              AFR            158              1.6            -3.0           -4.6          345           95             596
                   Madagascar                           AFR            852              5.3            -3.2           -8.5         3454          948            5960
                   Malawi                               AFR            614              5.1            0.6            -4.5         1323          363            2283
                   Mali                                 AFR            787              5.0            -2.0           -7.0         2631          722            4540
                   Mozambique                           AFR           1099              6.0            -0.5           -6.5         3441          944            5937
                   Nepal                                SAR            562              6.3            0.0            -6.3         1681          461            2900
                   Niger                                AFR           1023              6.1            0.5            -5.6         2717          746            4688
                   Rwanda                               AFR            390              8.1            2.0            -6.1         1142          313            1970
                   Sierra Leone                         AFR            255              4.7            -3.1           -7.7          945          260            1631
                   Somalia                              AFR            622              3.2            -1.5           -4.7         1398          384            2412
                   South Sudan                          AFR            386              8.2            4.1            -4.1          757          208            1306
                   Tajikistan                           ECA            281              4.5            1.0            -3.5          470          129             811
                   Tanzania                             AFR           2052              5.7            1.9            -3.8         3732          1024           6440
                   Togo                                 AFR            260              5.3            0.0            -5.3          659          181            1137
                   Uganda                               AFR           1614              6.2            -0.3           -6.5         5022          1378           8666
                   Yemen, Rep.                          MNA            865              2.0            -5.0           -7.0         2890          793            4987




                                                                                                                             Shapira G, et al. BMJ Open 2021; 11:e050551. doi: 10.1136/bmjopen-2021-050551
                                        BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance
Supplemental material                              placed on this supplemental material which has been supplied by the author(s)                                                              BMJ Open




                   Panel B: Lower-Middle Income Economies a
                   Angola                            AFR                     1243                  1.2                 -4.0              -5.2        1523           832            2215
                   Bangladesh                        SAR                     2946                  7.4                 3.8               -3.6        2550           1393           3707
                   Bhutan                            SAR                      13                   7.2                 0.6               -6.6          21            11             30
                   Bolivia                           LAC                     247                   3.8                 -7.9             -11.7         685           374             996
                   Cabo Verde                        AFR                      11                   5.0                 -6.8             -11.7          30            16             43
                   Cambodia                          EAP                     366                   6.8                 -2.8              -9.5         828           452            1204
                   Cameroon                          AFR                     887                   4.2                 -2.8              -6.9        1461           798            2124
                   Comoros                           AFR                      26                   4.2                 -1.8              -6.1          38            21             55
                   Congo, Rep.                       AFR                     171                   2.8                 -7.0              -9.8         398           217             578
                   Côte d'Ivoire                     AFR                     890                   7.3                 1.8               -5.5        1161           634            1688
                   Djibouti                          AFR                      21                   6.0                 -1.0              -7.0          34            19             50
                   Egypt                             MNA                     2584                  5.9                 3.5               -2.3        1424           778            2070
                   El Salvador                       LAC                     118                   2.3                 -9.0             -11.3         315           172             458
                   Eswatini                          AFR                      30                   0.5                 -3.5              -4.0          29            16             41
                   Ghana                             AFR                     871                   5.6                 0.9               -4.7         968           529            1407
                   Honduras                          LAC                     207                   3.5                 -6.6             -10.1         496           271             721
                   India                             SAR                    24238                  7.0                -10.3             -17.3       99642          54424          144860
                   Indonesia                         EAP                     4842                  5.1                 -1.5              -6.6        7549           4123          10975
                   Kenya                             AFR                     1469                  6.0                 1.0               -5.0        1743           952            2533
                   Kiribati                          EAP                      3                    2.3                 -1.1              -3.4          3              1              4
                   Kyrgyz Republic                   ECA                     155                   3.4                -12.0             -15.4         566           309             823
                   Lao PDR                           EAP                     167                   6.5                 0.2               -6.3         250           136             363
                   Lesotho                           AFR                      57                   -0.2                -4.8              -4.6          62            34             91
                   Mauritania                        AFR                     147                   5.9                 -3.2              -9.1         318           174             463
                   Micronesia, Fed. Sts.             EAP                      3                    0.8                 -3.8              -4.6          3              2              4
                   Moldova                           ECA                      41                   3.8                 -4.5              -8.3          81            44             118
                   Mongolia                          EAP                      77                   5.4                 -2.0              -7.4         134            73             195
                   Morocco                           MNA                     682                   3.7                 -7.0             -10.7        1725           942            2508
                   Myanmar                           EAP                     948                   6.3                 2.0               -4.3         959           524            1395
                   Nicaragua                         LAC                     134                   -0.8                -5.5              -4.7         151            82             219
                   Nigeria                           AFR                     7377                  2.5                 -4.3              -6.8       11904           6502          17306
                   Pakistan                          SAR                     5994                  2.4                 -0.4              -2.7        3891           2125           5656
                   Papua New Guinea                  EAP                     232                   2.6                 -3.3              -5.8         322           176             468
                   Philippines                       EAP                     2178                  6.2                 -8.3             -14.4        7466           4078          10855




                                                                                                                           Shapira G, et al. BMJ Open 2021; 11:e050551. doi: 10.1136/bmjopen-2021-050551
                                        BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance
Supplemental material                              placed on this supplemental material which has been supplied by the author(s)                                                              BMJ Open




                   Senegal                           AFR                     544                   6.8                 -0.7              -7.4         961           525            1397
                   Solomon Islands                   EAP                      21                   2.9                 -5.0              -7.9          39            21             57
                   Sudan                             AFR                     1339                  -1.5                -8.4              -6.9        2182           1192           3172
                   São Tomé and Príncipe             AFR                      7                    3.5                 -6.5             -10.0          16             9             23
                   Timor-Leste                       EAP                      37                   5.0                 -6.8             -11.8         105            57             152
                   Tunisia                           MNA                     204                   2.4                 -7.0              -9.5         458           250             666
                   Ukraine                           ECA                     426                   3.0                 -7.2             -10.2        1032           564            1500
                   Uzbekistan                        ECA                     703                   6.0                 0.7               -5.3         884           483            1285
                   Vanuatu                           EAP                      9                    3.1                 -8.3             -11.4          23            13             34
                   Vietnam                           EAP                     1610                  6.5                 1.6               -4.9        1872           1023           2722
                   Zambia                            AFR                     622                   1.7                 -4.8              -6.5         963           526            1400
                   Zimbabwe                          AFR                     442                   2.7                -10.4             -13.1        1375           751            1999
                   Nigeria                           AFR                     7377                  2.5                 -4.3              -6.8       11904           832            2215
                   Pakistan                          SAR                     5994                  2.4                 -0.4              -2.7        3891           1393           3707
                   Papua New Guinea                  EAP                     232                   2.6                 -3.3              -5.8         322            11             30
                   Philippines                       EAP                     2178                  6.2                 -8.3             -14.4        7466           374             996
                   Senegal                           AFR                     544                   6.8                 -0.7              -7.4         961            16             43
                   Solomon Islands                   EAP                      21                   2.9                 -5.0              -7.9          39           452            1204
                   Sudan                             AFR                     1339                  -1.5                -8.4              -6.9        2182           798            2124
                   São Tomé and Príncipe             AFR                      7                    3.5                 -6.5             -10.0          16            21             55
                   Timor-Leste                       EAP                      37                   5.0                 -6.8             -11.8         105           217             578
                   Tunisia                           MNA                     204                   2.4                 -7.0              -9.5         458           634            1688
                   Ukraine                           ECA                     426                   3.0                 -7.2             -10.2        1032            19             50
                   Uzbekistan                        ECA                     703                   6.0                 0.7               -5.3         884           778            2070
                   Vanuatu                           EAP                      9                    3.1                 -8.3             -11.4          23           172             458
                   Vietnam                           EAP                     1610                  6.5                 1.6               -4.9        1872            16             41
                   Zambia                            AFR                     622                   1.7                 -4.8              -6.5         963           529            1407
                   Zimbabwe                          AFR                     442                   2.7                -10.4             -13.1        1375           271             721
                   Panel C: Upper-Middle Income Economies a
                   Albania                           ECA                      34                   4.0                 -7.5             -11.6         63              11            116
                   Algeria                           MNA                     1032                  2.4                 -5.5              -7.9       1305             223           2388
                   Argentina                         LAC                     755                   -1.3               -11.8             -10.5       1276             218           2333
                   Armenia                           ECA                      42                   4.8                 -4.5              -9.3         62              11            114
                   Azerbaijan                        ECA                     169                   2.1                 -4.0              -6.1        167              28            305
                   Belarus                           ECA                     112                   0.3                 -3.0              -3.3         59              10            108




                                                                                                                           Shapira G, et al. BMJ Open 2021; 11:e050551. doi: 10.1136/bmjopen-2021-050551
                                            BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance
Supplemental material                                  placed on this supplemental material which has been supplied by the author(s)                                                              BMJ Open




                   Belize                                     LAC                 8                    2.1                -16.0             -18.1          23             4             42
                   Bosnia and Herzegovina                     ECA                 27                   2.6                 -6.5              -9.1          40             7             74
                   Botswana                                   AFR                 56                   4.3                 -9.6             -14.0         126            22             231
                   Brazil                                     LAC                2934                  2.0                 -5.8              -7.8        3700           632            6768
                   Bulgaria                                   ECA                 63                   3.2                 -4.0              -7.2          73            13             134
                   China                                      EAP               16978                  5.8                 1.9               -4.0       10835           1852          19818
                   Colombia                                   LAC                739                   3.6                 -8.2             -11.8        1407           240            2573
                   Costa Rica                                 LAC                 70                   2.5                 -5.5              -8.0          91            15             166
                   Dominican Republic                         LAC                208                   5.2                 -6.0             -11.2         375            64             686
                   Ecuador                                    LAC                336                   0.5                -11.0             -11.5         621           106            1135
                   Equatorial Guinea                          AFR                 43                   -5.0                -6.0              -1.0          7              1             13
                   Fiji                                       EAP                 19                   3.0                -21.0             -24.0          73            13             134
                   Gabon                                      AFR                 67                   3.4                 -2.7              -6.1          65            11             120
                   Georgia                                    ECA                 54                   4.8                 -5.0              -9.8          86            15             157
                   Grenada                                    LAC                 2                    2.7                -11.8             -14.5          4              1              8
                   Guatemala                                  LAC                423                   3.5                 -2.0              -5.5         377            64             690
                   Guyana                                     LAC                 16                   85.6                26.2             -59.4         149            25             273
                   Iran                                       MNA                1552                  0.0                 -5.0              -5.0        1257           215            2298
                   Iraq                                       MNA                1104                  4.7                -12.1             -16.7        2972           508            5436
                   Jamaica                                    LAC                 47                   1.0                 -8.6              -9.6          73            13             134
                   Jordan                                     MNA                215                   2.4                 -5.0              -7.4         255            44             467
                   Kazakhstan                                 ECA                389                   3.9                 -2.7              -6.6         413            71             756
                   Lebanon                                    MNA                117                   0.9                -25.0             -25.9         488            83             893
                   Libya                                      MNA                126                   0.0                -66.7             -66.6        1353           231            2475
                   Malaysia                                   EAP                527                   4.4                 -6.0             -10.4         882           151            1613
                   Maldives                                   SAR                 7                    6.0                -18.6             -24.6          28             5             52
                   Mauritius                                  AFR                 13                   3.8                -14.2             -18.0          38             6             69
                   Mexico                                     LAC                2224                  1.3                 -9.0             -10.3        3670           627            6713
                   Montenegro                                 ECA                 7                    2.5                -12.0             -14.5          17             3             32
                   Namibia                                    AFR                 70                   1.6                 -5.9              -7.4          83            14             153
                   North Macedonia                            ECA                 23                   3.4                 -5.4              -8.8          32             5             58
                   Paraguay                                   LAC                143                   4.0                 -4.0              -8.0         185            32             338
                   Peru                                       LAC                574                   3.6                -13.9             -17.6        1621           277            2966
                   Romania                                    ECA                192                   3.5                 -4.8              -8.3         256            44             468
                   Russia                                     ECA                1858                  1.9                 -4.1              -6.0        1788           306            3271




                                                                                                                               Shapira G, et al. BMJ Open 2021; 11:e050551. doi: 10.1136/bmjopen-2021-050551
                                              BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance
Supplemental material                                    placed on this supplemental material which has been supplied by the author(s)                                                              BMJ Open




                      Samoa                                      EAP                5                    4.4                 -5.0              -9.4         7                1            13
                      Serbia                                     ECA                84                   4.0                 -2.5              -6.5         87              15            160
                      South Africa                               AFR               1185                  1.1                 -8.0              -9.1       1730             296           3165
                      Sri Lanka                                  SAR               339                   3.5                 -4.6              -8.1        441              75            806
                      St. Lucia                                  LAC                2                    3.2                -16.9             -20.1         7                1            13
                      St. Vincent and the Grenadines             LAC                2                    2.3                 -7.0              -9.3         2                0             4
                      Suriname                                   LAC                11                   2.5                -13.1             -15.6         27               5            49
                      Thailand                                   EAP               725                   3.0                 -7.1             -10.2       1183             202           2164
                      Tonga                                      EAP                3                    3.7                 -2.5              -6.2         3                0             5
                      Turkey                                     ECA               1318                  3.0                 -5.0              -8.0       1689             289           3089
                      Turkmenistan                               ECA               139                   6.0                 1.8               -4.3         95              16            174
                      Venezuela, RB                              LAC               528                  -10.0               -25.0             -15.0       1273             218           2328
                  a
                    The country classification into income and region groups follows the World Bank classification for fiscal year 2021. AFR = sub-Saharan Africa; EAP = East
                  Asia and Pacific; ECA = European and Central Asia; LAC = Latin America and Caribbean; MNA = Middle East and North Africa SAR = South Asia;
                  b
                    Number of births projected by the United Nations World Population Prospects 2019.
                  c
                    Projections by the IMF World Economic Outlook for 2020.




                                                                                                                                 Shapira G, et al. BMJ Open 2021; 11:e050551. doi: 10.1136/bmjopen-2021-050551
                                    BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance
Supplemental material                      placed on this supplemental material which has been supplied by the author(s)                          BMJ Open




                            Appendix Table A1: Demographic and Health Surveys datasets used in the analysis
                        Low-income                        Lower-middle income                      Upper-middle income
           Afghanistan 2015                      Angola 2016                               Albania 2009, 2018
           Benin 1996, 2001, 2006, 2012, 2018    Bangladesh 1994, 1997, 2000, 2004,        Armenia 2000, 2005, 2010, 2016
           Burkina Faso 1993, 1999, 2003, 2010           2007, 2011, 2014                  Azerbaijan 2006
           Burundi 1987, 2011, 2017              Bolivia 1989, 1994, 1998, 2004, 2008      Brazil 1986, 1992, 1996
           Central African Republic 1995         Cambodia 2000, 2006, 2011, 2014           Colombia 1986, 1990, 1995, 2000,
           DRC 2007, 2014                        Cameroon 1991, 1998, 2004, 2011, 2018             2005, 2010, 2016
           Ethiopia 2000, 2005, 2011, 2016       Comoros 1996, 2012                        Dominican Republic 1986, 1991,
           Gambia 2013                           Republic of Congo 2005, 2012                      1996, 1999, 2002, 2007, 2013
           Guinea 1999, 2005, 2012, 2018         Cote d’Ivoire 1994, 1999, 2012            Ecuador 1987
           Haiti 1995, 2000, 2006, 2012, 2017    Egypt 1989, 1993, 1996, 2003, 2005,       Gabon 2001, 2012
           Liberia 2007, 2013                            2008, 2014                        Guatemala 1987, 1995, 1999, 2015
           Madagascar 1992, 1997, 2004, 2009     El Salvador 1985                          Guyana 2009
           Malawi 1992, 2000, 2005, 2010, 2016 Eswatini 2007                               Jordan 1990, 1997, 2002, 2007, 2012,
           Mali 1987, 1996, 2001, 2006, 2013,    Ghana 1988, 1994, 2003, 2008, 2014                2018
                   2018                          Honduras 2006, 2012                       Kazakhstan 1995, 1999
           Mozambique 1997, 2004, 2011, 2015     India 1993, 1999, 2006, 2016              Maldives 2009, 2017
           Nepal 1997, 2001, 2006, 2011, 2017    Indonesia 1987, 1991, 1994, 1997, 2003,   Mexico 1987
           Niger 1992, 1998, 2006, 2012                  2007, 2012, 2017                  Namibia 1992, 2000, 2007, 2013
           Rwanda 1992, 2000, 2008, 2011, 2015 Kenya 1989, 1993, 1998, 2003, 2009,         Paraguay 1990
           Sierra Leone 2008, 2013                       2014                              Peru 1986, 1992, 1996, 2000, 2004-
           Tajikistan 2012, 2017                 Kyrgyz Republic 1997, 2012                        2012*
           Tanzania 1999, 2005, 2012, 2016       Lesotho 2005, 2010, 2014
           Togo 1988, 1998, 2014                 Moldova 2005
           Uganda 1989, 1995, 2001, 2006         Morocco1987, 1992, 2004
           Yemen 1992, 2013                      Myanmar 2016
                                                 Nicaragua 1998, 2001
                                                 Nigeria 1990, 2003, 2008, 2013, 2018
                                                 Pakistan 1991, 2007, 2013, 2018
                                                 Papua New Guinea 2018
                                                 Philippines 1993, 1998, 2003, 2008, 2013,
                                                         2017
                                                 Sao Tome and Principe 2009
                                                 Senegal 1986, 1993, 1997, 2011, 2012-
                                                         2018*
                                                 Sudan 1990
                                                 Timor Leste 2010, 2016
                                                 Tunisia 1988
                                                 Ukraine 2007
                                                 Uzbekistan 1996
                                                 Vietnam 1997, 2002
                                                 Zambia 1992, 1997, 2002, 2007, 2014,
                                                         2018
                                                 Zimbabwe 1989, 1994, 1999, 2006, 2011,
                                                         2015
                   Notes: The years denote the timing of survey implementation in each country. Some surveys spanned over more
                   than one calendar year. In these cases, the last year of the survey is indicated. For the analysis, retrospective birth
                   histories are used to create birth and infant mortality data for the 11 years preceding each survey.
                   * Senegal and Peru had special continuous surveys. Peru had annual survey between 2004 and 2012 and Senegal
                   completed annual surveys between 2012 to 2018.




                                                                               Shapira G, et al. BMJ Open 2021; 11:e050551. doi: 10.1136/bmjopen-2021-050551
                                          BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance
Supplemental material                                placed on this supplemental material which has been supplied by the author(s)                                                              BMJ Open




                            Appendix Table A2: Projections of growth shortfall and excess infant mortality in lower- and middle-income countries
                                                                   Number of          WEO projections of 2020 growth c                Excess mortality projection
                                                                  annual birth       October        October
                                                                  2015-2020 (in        2019           2020         Growth                     95% lower 95% higher
                                Country               Region a    thousands) b      projection     projection      Shortfall     estimate       bound          bound
                   Panel A: Lower Income Economies a
                   Afghanistan                          SAR           1205              3.5            -5.0           -8.5         4888          1342           8434
                   Benin                                AFR            413              6.7            2.0            -4.7          930          255            1604
                   Burkina Faso                         AFR            745              6.0            -2.0           -8.0         2852          783            4920
                   Burundi                              AFR            433              0.5            -3.2           -3.7          775          213            1338
                   Central African Republic             AFR            165              5.0            -1.0           -5.9          468          128             807
                   Chad                                 AFR            648              5.4            -0.7           -6.1         1894          520            3267
                   Congo, Dem. Rep.                     AFR           3434              3.9            -2.2           -6.0         9925          2724          17126
                   Eritrea                              AFR            106              3.9            -0.6           -4.5          226           62             391
                   Ethiopia                             AFR           3514              7.2            1.9            -5.3         8832          2424          15240
                   Gambia, The                          AFR             87              6.4            -1.8           -8.2          343           94             591
                   Guinea                               AFR            449              6.0            1.4            -4.5          970          266            1673
                   Guinea-Bissau                        AFR             66              4.9            -2.9           -7.8          245           67             422
                   Haiti                                LAC            271              1.2            -4.0           -5.2          674          185            1164
                   Liberia                              AFR            158              1.6            -3.0           -4.6          345           95             596
                   Madagascar                           AFR            852              5.3            -3.2           -8.5         3454          948            5960
                   Malawi                               AFR            614              5.1            0.6            -4.5         1323          363            2283
                   Mali                                 AFR            787              5.0            -2.0           -7.0         2631          722            4540
                   Mozambique                           AFR           1099              6.0            -0.5           -6.5         3441          944            5937
                   Nepal                                SAR            562              6.3            0.0            -6.3         1681          461            2900
                   Niger                                AFR           1023              6.1            0.5            -5.6         2717          746            4688
                   Rwanda                               AFR            390              8.1            2.0            -6.1         1142          313            1970
                   Sierra Leone                         AFR            255              4.7            -3.1           -7.7          945          260            1631
                   Somalia                              AFR            622              3.2            -1.5           -4.7         1398          384            2412
                   South Sudan                          AFR            386              8.2            4.1            -4.1          757          208            1306
                   Tajikistan                           ECA            281              4.5            1.0            -3.5          470          129             811
                   Tanzania                             AFR           2052              5.7            1.9            -3.8         3732          1024           6440
                   Togo                                 AFR            260              5.3            0.0            -5.3          659          181            1137
                   Uganda                               AFR           1614              6.2            -0.3           -6.5         5022          1378           8666
                   Yemen, Rep.                          MNA            865              2.0            -5.0           -7.0         2890          793            4987




                                                                                                                             Shapira G, et al. BMJ Open 2021; 11:e050551. doi: 10.1136/bmjopen-2021-050551
                                        BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance
Supplemental material                              placed on this supplemental material which has been supplied by the author(s)                                                              BMJ Open




                   Panel B: Lower-Middle Income Economies a
                   Angola                            AFR                     1243                  1.2                 -4.0              -5.2        1523           832            2215
                   Bangladesh                        SAR                     2946                  7.4                 3.8               -3.6        2550           1393           3707
                   Bhutan                            SAR                      13                   7.2                 0.6               -6.6          21            11             30
                   Bolivia                           LAC                     247                   3.8                 -7.9             -11.7         685           374             996
                   Cabo Verde                        AFR                      11                   5.0                 -6.8             -11.7          30            16             43
                   Cambodia                          EAP                     366                   6.8                 -2.8              -9.5         828           452            1204
                   Cameroon                          AFR                     887                   4.2                 -2.8              -6.9        1461           798            2124
                   Comoros                           AFR                      26                   4.2                 -1.8              -6.1          38            21             55
                   Congo, Rep.                       AFR                     171                   2.8                 -7.0              -9.8         398           217             578
                   Côte d'Ivoire                     AFR                     890                   7.3                 1.8               -5.5        1161           634            1688
                   Djibouti                          AFR                      21                   6.0                 -1.0              -7.0          34            19             50
                   Egypt                             MNA                     2584                  5.9                 3.5               -2.3        1424           778            2070
                   El Salvador                       LAC                     118                   2.3                 -9.0             -11.3         315           172             458
                   Eswatini                          AFR                      30                   0.5                 -3.5              -4.0          29            16             41
                   Ghana                             AFR                     871                   5.6                 0.9               -4.7         968           529            1407
                   Honduras                          LAC                     207                   3.5                 -6.6             -10.1         496           271             721
                   India                             SAR                    24238                  7.0                -10.3             -17.3       99642          54424          144860
                   Indonesia                         EAP                     4842                  5.1                 -1.5              -6.6        7549           4123          10975
                   Kenya                             AFR                     1469                  6.0                 1.0               -5.0        1743           952            2533
                   Kiribati                          EAP                      3                    2.3                 -1.1              -3.4          3              1              4
                   Kyrgyz Republic                   ECA                     155                   3.4                -12.0             -15.4         566           309             823
                   Lao PDR                           EAP                     167                   6.5                 0.2               -6.3         250           136             363
                   Lesotho                           AFR                      57                   -0.2                -4.8              -4.6          62            34             91
                   Mauritania                        AFR                     147                   5.9                 -3.2              -9.1         318           174             463
                   Micronesia, Fed. Sts.             EAP                      3                    0.8                 -3.8              -4.6          3              2              4
                   Moldova                           ECA                      41                   3.8                 -4.5              -8.3          81            44             118
                   Mongolia                          EAP                      77                   5.4                 -2.0              -7.4         134            73             195
                   Morocco                           MNA                     682                   3.7                 -7.0             -10.7        1725           942            2508
                   Myanmar                           EAP                     948                   6.3                 2.0               -4.3         959           524            1395
                   Nicaragua                         LAC                     134                   -0.8                -5.5              -4.7         151            82             219
                   Nigeria                           AFR                     7377                  2.5                 -4.3              -6.8       11904           6502          17306
                   Pakistan                          SAR                     5994                  2.4                 -0.4              -2.7        3891           2125           5656
                   Papua New Guinea                  EAP                     232                   2.6                 -3.3              -5.8         322           176             468
                   Philippines                       EAP                     2178                  6.2                 -8.3             -14.4        7466           4078          10855




                                                                                                                           Shapira G, et al. BMJ Open 2021; 11:e050551. doi: 10.1136/bmjopen-2021-050551
                                        BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance
Supplemental material                              placed on this supplemental material which has been supplied by the author(s)                                                              BMJ Open




                   Senegal                           AFR                     544                   6.8                 -0.7              -7.4         961           525            1397
                   Solomon Islands                   EAP                      21                   2.9                 -5.0              -7.9          39            21             57
                   Sudan                             AFR                     1339                  -1.5                -8.4              -6.9        2182           1192           3172
                   São Tomé and Príncipe             AFR                      7                    3.5                 -6.5             -10.0          16             9             23
                   Timor-Leste                       EAP                      37                   5.0                 -6.8             -11.8         105            57             152
                   Tunisia                           MNA                     204                   2.4                 -7.0              -9.5         458           250             666
                   Ukraine                           ECA                     426                   3.0                 -7.2             -10.2        1032           564            1500
                   Uzbekistan                        ECA                     703                   6.0                 0.7               -5.3         884           483            1285
                   Vanuatu                           EAP                      9                    3.1                 -8.3             -11.4          23            13             34
                   Vietnam                           EAP                     1610                  6.5                 1.6               -4.9        1872           1023           2722
                   Zambia                            AFR                     622                   1.7                 -4.8              -6.5         963           526            1400
                   Zimbabwe                          AFR                     442                   2.7                -10.4             -13.1        1375           751            1999
                   Nigeria                           AFR                     7377                  2.5                 -4.3              -6.8       11904           832            2215
                   Pakistan                          SAR                     5994                  2.4                 -0.4              -2.7        3891           1393           3707
                   Papua New Guinea                  EAP                     232                   2.6                 -3.3              -5.8         322            11             30
                   Philippines                       EAP                     2178                  6.2                 -8.3             -14.4        7466           374             996
                   Senegal                           AFR                     544                   6.8                 -0.7              -7.4         961            16             43
                   Solomon Islands                   EAP                      21                   2.9                 -5.0              -7.9          39           452            1204
                   Sudan                             AFR                     1339                  -1.5                -8.4              -6.9        2182           798            2124
                   São Tomé and Príncipe             AFR                      7                    3.5                 -6.5             -10.0          16            21             55
                   Timor-Leste                       EAP                      37                   5.0                 -6.8             -11.8         105           217             578
                   Tunisia                           MNA                     204                   2.4                 -7.0              -9.5         458           634            1688
                   Ukraine                           ECA                     426                   3.0                 -7.2             -10.2        1032            19             50
                   Uzbekistan                        ECA                     703                   6.0                 0.7               -5.3         884           778            2070
                   Vanuatu                           EAP                      9                    3.1                 -8.3             -11.4          23           172             458
                   Vietnam                           EAP                     1610                  6.5                 1.6               -4.9        1872            16             41
                   Zambia                            AFR                     622                   1.7                 -4.8              -6.5         963           529            1407
                   Zimbabwe                          AFR                     442                   2.7                -10.4             -13.1        1375           271             721
                   Panel C: Upper-Middle Income Economies a
                   Albania                           ECA                      34                   4.0                 -7.5             -11.6         63              11            116
                   Algeria                           MNA                     1032                  2.4                 -5.5              -7.9       1305             223           2388
                   Argentina                         LAC                     755                   -1.3               -11.8             -10.5       1276             218           2333
                   Armenia                           ECA                      42                   4.8                 -4.5              -9.3         62              11            114
                   Azerbaijan                        ECA                     169                   2.1                 -4.0              -6.1        167              28            305
                   Belarus                           ECA                     112                   0.3                 -3.0              -3.3         59              10            108




                                                                                                                           Shapira G, et al. BMJ Open 2021; 11:e050551. doi: 10.1136/bmjopen-2021-050551
                                            BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance
Supplemental material                                  placed on this supplemental material which has been supplied by the author(s)                                                              BMJ Open




                   Belize                                     LAC                 8                    2.1                -16.0             -18.1          23             4             42
                   Bosnia and Herzegovina                     ECA                 27                   2.6                 -6.5              -9.1          40             7             74
                   Botswana                                   AFR                 56                   4.3                 -9.6             -14.0         126            22             231
                   Brazil                                     LAC                2934                  2.0                 -5.8              -7.8        3700           632            6768
                   Bulgaria                                   ECA                 63                   3.2                 -4.0              -7.2          73            13             134
                   China                                      EAP               16978                  5.8                 1.9               -4.0       10835           1852          19818
                   Colombia                                   LAC                739                   3.6                 -8.2             -11.8        1407           240            2573
                   Costa Rica                                 LAC                 70                   2.5                 -5.5              -8.0          91            15             166
                   Dominican Republic                         LAC                208                   5.2                 -6.0             -11.2         375            64             686
                   Ecuador                                    LAC                336                   0.5                -11.0             -11.5         621           106            1135
                   Equatorial Guinea                          AFR                 43                   -5.0                -6.0              -1.0          7              1             13
                   Fiji                                       EAP                 19                   3.0                -21.0             -24.0          73            13             134
                   Gabon                                      AFR                 67                   3.4                 -2.7              -6.1          65            11             120
                   Georgia                                    ECA                 54                   4.8                 -5.0              -9.8          86            15             157
                   Grenada                                    LAC                 2                    2.7                -11.8             -14.5          4              1              8
                   Guatemala                                  LAC                423                   3.5                 -2.0              -5.5         377            64             690
                   Guyana                                     LAC                 16                   85.6                26.2             -59.4         149            25             273
                   Iran                                       MNA                1552                  0.0                 -5.0              -5.0        1257           215            2298
                   Iraq                                       MNA                1104                  4.7                -12.1             -16.7        2972           508            5436
                   Jamaica                                    LAC                 47                   1.0                 -8.6              -9.6          73            13             134
                   Jordan                                     MNA                215                   2.4                 -5.0              -7.4         255            44             467
                   Kazakhstan                                 ECA                389                   3.9                 -2.7              -6.6         413            71             756
                   Lebanon                                    MNA                117                   0.9                -25.0             -25.9         488            83             893
                   Libya                                      MNA                126                   0.0                -66.7             -66.6        1353           231            2475
                   Malaysia                                   EAP                527                   4.4                 -6.0             -10.4         882           151            1613
                   Maldives                                   SAR                 7                    6.0                -18.6             -24.6          28             5             52
                   Mauritius                                  AFR                 13                   3.8                -14.2             -18.0          38             6             69
                   Mexico                                     LAC                2224                  1.3                 -9.0             -10.3        3670           627            6713
                   Montenegro                                 ECA                 7                    2.5                -12.0             -14.5          17             3             32
                   Namibia                                    AFR                 70                   1.6                 -5.9              -7.4          83            14             153
                   North Macedonia                            ECA                 23                   3.4                 -5.4              -8.8          32             5             58
                   Paraguay                                   LAC                143                   4.0                 -4.0              -8.0         185            32             338
                   Peru                                       LAC                574                   3.6                -13.9             -17.6        1621           277            2966
                   Romania                                    ECA                192                   3.5                 -4.8              -8.3         256            44             468
                   Russia                                     ECA                1858                  1.9                 -4.1              -6.0        1788           306            3271




                                                                                                                               Shapira G, et al. BMJ Open 2021; 11:e050551. doi: 10.1136/bmjopen-2021-050551
                                              BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance
Supplemental material                                    placed on this supplemental material which has been supplied by the author(s)                                                              BMJ Open




                      Samoa                                      EAP                5                    4.4                 -5.0              -9.4         7                1            13
                      Serbia                                     ECA                84                   4.0                 -2.5              -6.5         87              15            160
                      South Africa                               AFR               1185                  1.1                 -8.0              -9.1       1730             296           3165
                      Sri Lanka                                  SAR               339                   3.5                 -4.6              -8.1        441              75            806
                      St. Lucia                                  LAC                2                    3.2                -16.9             -20.1         7                1            13
                      St. Vincent and the Grenadines             LAC                2                    2.3                 -7.0              -9.3         2                0             4
                      Suriname                                   LAC                11                   2.5                -13.1             -15.6         27               5            49
                      Thailand                                   EAP               725                   3.0                 -7.1             -10.2       1183             202           2164
                      Tonga                                      EAP                3                    3.7                 -2.5              -6.2         3                0             5
                      Turkey                                     ECA               1318                  3.0                 -5.0              -8.0       1689             289           3089
                      Turkmenistan                               ECA               139                   6.0                 1.8               -4.3         95              16            174
                      Venezuela, RB                              LAC               528                  -10.0               -25.0             -15.0       1273             218           2328
                  a
                    The country classification into income and region groups follows the World Bank classification for fiscal year 2021. AFR = sub-Saharan Africa; EAP = East
                  Asia and Pacific; ECA = European and Central Asia; LAC = Latin America and Caribbean; MNA = Middle East and North Africa SAR = South Asia;
                  b
                    Number of births projected by the United Nations World Population Prospects 2019.
                  c
                    Projections by the IMF World Economic Outlook for 2020.




                                                                                                                                 Shapira G, et al. BMJ Open 2021; 11:e050551. doi: 10.1136/bmjopen-2021-050551