Understanding causes of death of children under 5: a multi-country analysis using verbal autopsy

Abstract

BackgroundDespite high levels of under-5 mortality in sub-Saharan Africa, reliable national estimates of causes of death are lacking for most countries. Most deaths occur outside of the health-care system. Information about causes of death is essential to inform policy and programme performance. In this study, we analysed the causes of death among children under-5 using verbal autopsy (VA) surveys implemented in Ghana, Mozambique, Rwanda, and Uganda. MethodsIn the four countries, VA surveys were conducted following Demographic and Health Surveys or National Censuses to gather nationally representative data on under-5 mortality. In all countries, two VA questionnaires were administered in households of a deceased child: one for neonatal deaths (0–28 days) and another for childhood deaths (29 days to 59 months). Questionnaires were reviewed by physicians trained in International Classification of Diseases-10 classification to determine cause of death. FindingsVerbal autopsies were conducted in Uganda (n=525), Rwanda, (n=361), Ghana (n=194), and Mozambique (n=3859). In Uganda, Rwanda, and Ghana, maternal factors and complications during pregnancy, labour, and delivery were the largest cause of neonatal deaths (deaths between 0 and 28 days of life; 20%, 42%, and 70%, respectively) while sepsis was the highest cause in Mozambique (35%). In all countries but Rwanda, malaria was the number one cause of childhood deaths (deaths between 29 days and 59 months), ranging from 42% to as high as 51% of all childhood deaths. In Rwanda, malaria was the third largest contributor to childhood deaths (15%), after pneumonia (19%) and diarrhoea (18%). Other major causes of childhood death were diarrhoea, pneumonia, and malnutrition. Analyses are weighted to account for study design and national representativeness. InterpretationMaternal factors and complications during pregnancy, labour, and delivery were the main cause of neonatal deaths in all countries but Mozambique, while malaria was the lead cause of childhood death in every country but Rwanda. Conducting VA through nationally representative surveys can provide valuable information on causes of death among children under age 5 years. FundingFunding for this study was provided to the MEASURE Evaluation Project by the United States Agency for International Development (USAID) through Cooperative Agreement GHA-A-00-08-00003-00. MEASURE Evaluation is implemented by the Carolina Population Center at the University of North Carolina at Chapel Hill, in partnership with Futures Group International, ICF Macro, John Snow, Inc., Management Sciences for Health, and Tulane University. USAID provided financial support for the implementation of the surveys on which this study is based through the MEASURE DHS programme implemented by IFC Macro. Local costs for the Ghana survey were partially funded by the Ghana Ministry of Health, the Ghana Statistical Service, the Ghana AIDS Commission, UNICEF, United Nations Population Fund United Nations Population Fund (UNFPA), and the Danish International Development Agency.