To analyse the mortality rates, causes of death and trends over time in children aged under five years in Henan province and to provide preventive advice to attempt to decrease the mortality rates of these children, a retrospective study was conducted, analysing the vital statistics data from 2004 to 2008 from the annual report of maternal and child health in Henan. The early neonatal (<7 days), neonatal (<28 days), infant (<1 year) and children under-five mortality rates were calculated for each year. The child mortality rates decreased in all age groups (early neonatal, neonatal, infants and children <5 years) from 2004 (7.44 per thousand, 9.81 per thousand, 12.08 per thousand and 14.04 per thousand, respectively) to 2008 (4.86 per thousand, 5.50 per thousand, 7.08 per thousand and 8.81 per thousand, respectively). The changes were more pronounced in the rural areas. However, child mortality remained higher in the rural areas (5.00 per thousand, 5.62 per thousand, 7.22 per thousand and 9.06 per thousand) than urban areas (3.98 per thousand, 4.74 per thousand, 6.21 per thousand and 7.30 per thousand). Infants and neonates accounted for a large proportion of deaths in the under-fives (84.5% and 67.9%). The first five leading causes of death in the under-fives were: disorders relating to short gestation and low birthweight, birth asphyxia, congenital anomalies, accidents and pneumonia. The leading causes of death in different age groups varied between rural and urban areas. Reducing early newborn death, especially in the rural areas, is a key step to further decreasing mortality in the under-fives. Attention should be paid to perinatal care to prevent preterm birth and congenital anomalies.