Abstract
BackgroundTrends in the causes of child mortality serve as important global health information to guide efforts to improve child survival. With child mortality declining in Bangladesh, the distribution of causes of death also changes. The three verbal autopsy (VA) studies conducted with the Bangladesh Demographic and Health Surveys provide a unique opportunity to study these changes in child causes of death.MethodsTo ensure comparability of these trends, we developed a standardized algorithm to assign causes of death using symptoms collected through the VA studies. The original algorithms applied were systematically reviewed and key differences in cause categorization, hierarchy, case definition, and the amount of data collected were compared to inform the development of the standardized algorithm. Based primarily on the 2004 cause categorization and hierarchy, the standardized algorithm guarantees comparability of the trends by only including symptom data commonly available across all three studies.ResultsBetween 1993 and 2004, pneumonia remained the leading cause of death in Bangladesh, contributing to 24% to 33% of deaths among children under 5. The proportion of neonatal mortality increased significantly from 36% (uncertainty range [UR]: 31%-41%) to 56% (49%-62%) during the same period. The cause-specific mortality fractions due to birth asphyxia/birth injury and prematurity/low birth weight (LBW) increased steadily, with both rising from 3% (2%-5%) to 13% (10%-17%) and 10% (7%-15%), respectively. The cause-specific mortality rates decreased significantly due to neonatal tetanus and several postneonatal causes (tetanus: from 7 [4-11] to 2 [0.4-4] per 1,000 live births (LB); pneumonia: from 26 [20-33] to 15 [11-20] per 1,000 LB; diarrhea: from 12 [8-17] to 4 [2-7] per 1,000 LB; measles: from 5 [2-8] to 0.2 [0-0.7] per 1,000 LB; injury: from 11 [7-17] to 3 [1-5] per 1,000 LB; and malnutrition: from 9 [6-13] to 5 [2-7]).ConclusionsPneumonia remained the top killer of children under 5 in Bangladesh between 1993 and 2004. The increasing importance of neonatal survival is highlighted by the growing contribution of neonatal deaths and several neonatal causes. Notwithstanding the limitations, standardized computer-based algorithms remain a promising tool to generate comparable causes of child death using VA data.
Highlights
Trends in the causes of child mortality serve as important global health information to guide efforts to improve child survival
Trends in the cause-specific fractions In Bangladesh, the under-5 mortality rate dropped from 128 deaths per 1,000 live births (LB) in 19931994 to 110 in 1996-1997, and to 70 per 1,000 LB in 2004 [4]
Corresponding to the reduction in under-5 mortality, the proportion of neonatal deaths increased significantly from 36% (UR: 31%-41%) to 41% (37%-46%) and to 56% (49%62%) in the three verbal autopsy (VA) studies (Figure 2, refer to Additional file 2 for a complete list of uncertainty estimates)
Summary
Trends in the causes of child mortality serve as important global health information to guide efforts to improve child survival. With child mortality declining in Bangladesh, the distribution of causes of death changes. Child mortality rates are declining in many countries [3,4]. During the same period of time, the neonatal mortality rate dropped from 58 to 30 deaths per 1,000 LB. Neonatal deaths contributed 57% of all under-5 deaths in 2009, compared to only 39% two decades earlier. Accompanying this steady decline in child mortality is a changing distribution of child causes of deaths [1,5], which has not been well described previously
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