Circumstances of child deaths in Mali and Uganda: a community-based confidential enquiry.

Merlin Willcox ,Florence Nakaggwa,Joseph Ngonzi,Drissa Diallo,Mamadou Traoré,Anthony Harnden,Chiaka Diakité,Diafara Berthé,Elias Kumbakumba,Kieran Dinwoodie,David Mant,Pierre Daou,Peter Kirabira,Nick Wooding,Birungi Mutahunga,Hamish Foster,Jerome Kabakyenga,Rowena Neville,Drissa Bamba,Vincent Mubangizi,S Capewell ,Amadou S Traoré ,Eugène Dembélé

doi:10.1016/s2214-109x(18)30215-8

Abstract

Interventions to reduce child deaths in Africa have often underachieved, causing the Millennium Development Goal targets to be missed. We assessed whether a community enquiry into the circumstances of death could improve intervention effectiveness by identifying local avoidable factors and explaining implementation failures. Deaths of children younger than 5 years were ascertained by community informants in two districts in Mali (762 deaths) and three districts in Uganda (442 deaths) in 2011-15. Deaths were investigated by interviewing parents and health workers. Investigation findings were reviewed by a panel of local health-care workers and community representatives, who formulated recommendations to address avoidable factors and, subsequently, oversaw their implementation. At least one avoidable factor was identified in 97% (95% CI 96-98, 737 of 756) of deaths in children younger than 5 years in Mali and 95% (93-97, 389 of 409) in Uganda. Suboptimal newborn care was a factor in 76% (146 of 194) of neonatal deaths in Mali and 64% (134 of 194) in Uganda. The most frequent avoidable factor in postneonatal deaths was inadequate child protection (mainly child neglect) in Uganda (29%, 63 of 215) and malnutrition in Mali (22%, 124 of 562). 84% (618 of 736 in Mali, 328 of 391 in Uganda) of families had consulted a health-care provider for the fatal illness, but the quality of care was often inadequate. Even in official primary care clinics, danger signs were often missed (43% of cases in Mali [135 of 396], 39% in Uganda [30 of 78]), essential treatment was not given (39% in Mali [154 of 396], 35% in Uganda [27 of 78]), and patients who were seriously ill were not referred to a hospital in time (51% in Mali [202 of 396], 45% in Uganda [35 of 78]). Local recommendations focused on quality of care in health-care facilities and on community issues influencing treatment-seeking behaviour. Local investigation and review of circumstances of death of children in sub-Saharan Africa is likely to lead to more effective interventions than simple consideration of the biomedical causes of death. This approach discerned local public health priorities and implementable solutions to address the avoidable factors identified. European Union's 7th Framework Programme for research and technological development.

Highlights

Almost 3 million deaths are estimated to have occurred in children younger than 5 years in sub-Saharan Africa in 2015, accounting for nearly half of all global child deaths.[1]
The absolute number of deaths in subSaharan Africa is estimated to have fallen by only 24% since 1990.1 this rate of reduction needs to accelerate markedly to reach the Sustainable Development Goal of 25 or fewer under-5 deaths per 1000 livebirths by 2030.1 When this study started, in 2011, under-5 mortality was estimated to be 95 deaths per 1000 livebirths in Mali and 90 per 1000 in Uganda.[2,3]
We found several verbal or social autopsy studies that investigated causes of child death and identified some avoidable factors on the basis of closed questions, mainly about delay in the care process, but none had initiated local discussion of avoidable factors to identify solutions

Summary

Introduction

Almost 3 million deaths are estimated to have occurred in children younger than 5 years in sub-Saharan Africa in 2015, accounting for nearly half of all global child deaths.[1]. Some have argued that the majority of these deaths could be prevented by increasing the coverage of a small number of simple, evidence-based interventions focused on biomedical causes of death.[4,5,6] the effective implementation of these interventions is not straightforward—the effect on mortality is often disappointing, reflecting a local failure to deliver interventions with adequate quality of care.[7,8,9] A systematic review of trials[10] of evidence-based inter ventions to improve health care in sub-Saharan Africa showed that the variation in outcomes between local centres is often greater than the overall estimate of effect. It is important to understand the barriers to implementation that cause local variations in effectiveness.[11,12]

Methods

Results

Conclusion