84 The World Health Report 2005 The reversal of progress in neonatal health in sub-Saharan Africa is both concern ing and unusual. Historically, declines in child mortality have often reversed when the social context deteriorated. Within Europe, these reversals mostly affected older children, while remaining modest for neonatal mortality (13 ) The causes of the poor progress in reducing both neonatal and later childhood deaths in sub-Saharan Africa are likely to be many and complex Economic decline and conflict are likely to have played significant roles through their disruptive effect on access to health ser (14-16). The impact of the HIV/AIDS epidemic on mortality is less well established for newborns than for the post-neonatal period, but infants born to HIv-positive mothers are more likely to be stillborn or premature; they are also likely to have low APGAR scores' and very low birth weights(17, 18) Reductions in child mortality in many countries are at least partly driven by socio economic development: improvements in women's education and literacy, household income, environmental conditions(safe water supply, sanitation and housing), along with improvements in health services and child nutrition (19, 20 ). While neonatal mor tality is affected by these factors, they may have a greater impact in the post-neonatal and early childhood periods than for newborns(see Box 5. 1 ). Historical data further support this hypothesis. There is little evidence that the often dramatic reductions in infant and child mortality in Europe during the first few decades of the 20th century i The APGAR test evaluates a newborn' s physical condition Each year more than 4 million babies die within 28 days of coming into the world and nearly 3.3 million babies are stillborn.84 The World Health Report 2005 The reversal of progress in neonatal health in sub-Saharan Africa is both concern￾ing and unusual. Historically, declines in child mortality have often reversed when the social context deteriorated. Within Europe, these reversals mostly affected older children, while remaining modest for neonatal mortality (13). The causes of the poor progress in reducing both neonatal and later childhood deaths in sub-Saharan Africa are likely to be many and complex. Economic decline and conflict are likely to have played significant roles through their disruptive effect on access to health services (14–16). The impact of the HIV/AIDS epidemic on mortality is less well established for newborns than for the post-neonatal period, but infants born to HIV-positive mothers are more likely to be stillborn or premature; they are also likely to have low APGAR scores1 and very low birth weights (17, 18). Reductions in child mortality in many countries are at least partly driven by socio￾economic development: improvements in women’s education and literacy, household income, environmental conditions (safe water supply, sanitation and housing), along with improvements in health services and child nutrition (19, 20). While neonatal mor￾tality is affected by these factors, they may have a greater impact in the post-neonatal and early childhood periods than for newborns (see Box 5.1). Historical data further support this hypothesis. There is little evidence that the often dramatic reductions in infant and child mortality in Europe during the first few decades of the 20th century Each year more than 4 million babies die within 28 days of coming into the world, and nearly 3.3 million babies are stillborn. N. Behring-Chisholm/WHO 1 The APGAR test evaluates a newborn’s physical condition