Childhood Mortality In sub-Saharan Africa Research Articles

World Bank Structural Adjustment, Water, and Sanitation: A Cross-National Analysis of Child Mortality in Sub-Saharan Africa

The authors conduct a cross-national analysis that seeks to accomplish two important goals. First, they test dependency theory’s hypotheses that World Bank structural adjustment adversely affects child mortality in Sub-Saharan Africa. Second, they empirically evaluate the effect of access to clean water and basic sanitation on child mortality. In doing so, they use two-way fixed effects regression models to analyze child mortality using data on 31 nations and four time points (1990, 1995, 2000, and 2005). They find substantial support for their first goal relating to dependency theory that when a Sub-Saharan African nation is under a World Bank structural adjustment loan, then it tends to have higher levels of child mortality. They also find support for their second goal concerning the importance of including environmental variables in cross-national research on health. Specifically, they find that higher levels of access to an improved water source and an improved sanitation facility are associated with lower levels of child mortality within Sub-Saharan African nations. The authors conclude by discussing the findings, theoretical implications, methodological implications, policy suggestions, and possible directions for future research.

The effect of distance to a health facility on childhood mortality in rural Burkina Faso, West Africa

Objective: Adequate access to health care services is an essential factor for the reduction of child mortality in Sub-Saharan Africa. The aim of this study is to determine the effect of distance, measured as mean walking duration to the closest health facility, on infant and child mortality, with respect to a set of further conditional factors from a previous publication. Methods: Longitudinal population data for the inhabitants of 42 villages in Nouna district (n≈67.000) were available from the database of the Nouna Health and Demographic Surveillance System (HDSS) in rural Burkina Faso. 24555 children born between 1993 and 2005 within the HDSS were investigated in this study. Walking time from each village to the closest health facility was obtained for dry and rainy season and its impact on infant (<1 year) and child (1–4 years) mortality was studied using Cox and Poisson regression analysis. Findings: We observed 1566 and 1860 infant and childhood deaths, resulting in mortality rates of 66 and 23 deaths per 1000 person-years, respectively. Rates decreased significantly during the observation time. The estimated walking times ranged from 5 minutes to 8 hours. Using Cox regression, walking distance was shown to be a highly significant risk factor for infant mortality. A walking time over 4 hours increased the risk for infant mortality by about 60%. Children living in a village without a health facility have a 50% increased mortality, independent of the location of the village. Further influencing factors were sex, religion, ethnicity, death of mother, being a twin, birth spacing and age of mother. Poisson regression analysis yielded similar results. Conclusion: The findings of this study emphasize the importance of fast accessibility of health care for Sub-Saharan populations and demonstrate the need to improve health care in developing countries to achieve the Millennium Development Goals.

Reduction in Maternal and Child Mortality in Sub-Saharan Africa: The Yo-Yo Effect in Delivering on the Promises

Trends in maternal and child mortality (MCM) in sub-Saharan Africa do not follow the patterns seen in developed nations or match the funds and effort invested so far. This paper critically explores trends in MCM, global efforts to reduce MCM, and some of the underlying policies and programmatic issues that have shaped the slow progress or failure in reducing MCM in sub-Saharan Africa. We describe a "yo-yo" effect in policies and funding of Maternal and Child Health, Family Planning, and HIV/AIDS/STI programs in the region, and how this yo-yo effect may limit sustained community level reductions in MCM. We conclude by highlighting how renewed interest in the Alma-Ata declaration, particularly its primary health care concepts with their strong emphasis on horizontally integrated linkage of programs and resources, greater community involvement in program design and implementation, and economic development can contribute to sustainable reductions in MCM in the region.

Urban and Rural Differences Across Countries in Child Mortality in Sub-Saharan Africa

The purpose of this study is to investigate and document the differences between urban and rural areas across countries in sub-Saharan Africa (SSA) with respect to child mortality. We use recent data from Demographic and Health Surveys on 11 selected countries in SSA. Socioeconomic variables of household wealth, level of education of the mother, access to clinics, and other environmental variables are used as control variables in measuring the differences. The study employs logit regression to enable the use of the odds ratio to interpret differences across the urban and rural areas in SSA.

MIF(Macrophage Migration Inhibitory Factor) Promoter Polymorphisms and Susceptibility to Severe Malarial Anemia

Severe malarial anemia (SMA) resulting from Plasmodium falciparum infection is one of the leading causes of childhood mortality in sub-Saharan Africa. The innate immune mediator macrophage migration inhibitory factor (MIF) plays a critical role in the pathogenesis of SMA. To investigate the influence of MIF genetic variation on susceptibility to SMA, haplotypes of the MIF -173G/C and -794CATT5-8 polymorphisms were examined in a cohort of Kenyan children. A statistically significant relationship between increasing frequencies of longer CATT repeats at -794 and increasing severity of malarial anemia was observed. In addition, there was a strong association between lower MIF concentrations and longer CATT repeats. Multivariate logistic regression analyses demonstrated that the 6G haplotype (ie, MIF -794CATT6/-173G) was associated with protection against SMA, whereas carriers of the 7C or 8C haplotype had increased risk of developing SMA. Furthermore, carriers of the 7C or 8C haplotype had reduced plasma MIF levels during acute disease. The findings demonstrate that variation in the MIF promoter influences susceptibility to SMA and peripheral MIF production. However, the MIF -173 and -794 polymorphisms appear to have both independent and interactive effects on different measures of disease severity, suggesting that MIF plays a complex role in malarial pathogenesis.

Predictions of the Impact of Malaria Control Efforts on All-Cause Child Mortality in Sub-Saharan Africa

All-cause childhood mortality (ACCM) has been recommended as an indicator for evaluating the impact of malaria control efforts in parts of Africa where the malaria burden is high and vital registration systems are weak. As ACCM is not malaria-specific, we explored the relationship between ACCM and malaria mortality. First, we show that if malaria mortality is reduced by 50% in populations exposed to high-intensity malaria transmission, ACCM is predicted to decrease by approximately 17% (plausible values range from 12% to 25%). Second, if malaria interventions are scaled-up from very low (2%) to reasonably high coverage levels (70%), epidemiologic models predict that ACCM would decrease by approximately 17% or 18% (precision estimate: 15-19%). These results suggest that if malaria interventions are scaled-up to reach or exceed 70% coverage, it is plausible that a goal of reducing malaria mortality by 50% could be achieved. It is also likely that a pair of "typical"-size mortality surveys could detect this ACCM change as being statistically significant. Although existing models have important limitations, they could be improved by incorporating empirical results during scale-up of multiple interventions and by adding precision estimates and sensitivity analyses.

National Vitamin A Supplementation Coverage Survey among 6-59 Months Old Children in Guinea (West Africa)

Vitamin A deficiency (VAD) is a major contributor to child mortality in sub-Saharan Africa. Sustained control of VAD is essential to meet the Millennium Development Goal (MDG) for reduction of child mortality in Guinea. Since, twice yearly vitamin A supplementation (VAS), either coupled with National Immunization Days or stand-alone has been adopted as a key strategy to combat VAD in 6-59 months old children. The objectives of this survey were to describe national VAS coverage rates and related factors affecting VAS coverage among 6-59 months old Guinean children. In July 2003, a VAS coverage survey was implemented in Guinea. A cross-sectional random cluster survey was conducted to select Guinean children (n = 1950, 390 mother-child pairs per zone) aged 6-59 months. The country was divided into four agro-ecological zones with 30 clusters chosen per zone. Within each cluster, a random selection of 13 households with at least one child was carried out with random selection of one child per household. Data on characteristics of children, receipt of VAS, caregivers' socio-economic characteristics, vitamin A knowledge and practices of caregivers were collected by questionnaire. The national coverage rate of 68% is much lower than the official coverage rate of 93%. Middle Guinea, the region most affected by VAD, had the lowest coverage rate (58%). In order to increase overall VAS coverage and reduce regional disparities, it is suggested that mass VAS be organized on a regional level, prioritizing rural regions (Middle and Upper Guinea) and the city of Conakry.

Role of Monocyte-Acquired Hemozoin in Suppression of Macrophage Migration Inhibitory Factor in Children with Severe Malarial Anemia

Severe malarial anemia (SMA), caused by Plasmodium falciparum infections, is one of the leading causes of childhood mortality in sub-Saharan Africa. Although the molecular determinants of SMA are largely undefined, dysregulation in host-derived inflammatory mediators influences disease severity. Macrophage migration inhibitory factor (MIF) is an important regulator of innate inflammatory responses that has recently been shown to suppress erythropoiesis and promote pathogenesis of SMA in murine models. To examine the role of MIF in the development of childhood SMA, peripheral blood MIF production was examined in Kenyan children (aged <3 years, n = 357) with P. falciparum malarial anemia. All children in the study were free from bacteremia and human immunodeficiency virus type 1. Since deposition of malarial pigment (hemozoin [Hz]) contributes to suppression of erythropoiesis, the relationship between MIF concentrations and monocytic acquisition of Hz was also examined in vivo and in vitro. Circulating MIF concentrations declined with increasing severity of anemia and significantly correlated with peripheral blood leukocyte MIF transcripts. However, MIF concentrations in peripheral blood were not significantly associated with reticulocyte production. Multivariate regression analyses, controlling for age, gender, and parasitemia, further revealed that elevated levels of pigment-containing monocytes (PCM) was associated with SMA and decreased MIF production. In addition, PCM levels were a better predictor of hemoglobin and MIF concentrations than parasite density. Additional experiments in malaria-naive individuals demonstrated that hemozoin caused both increased and decreased MIF production in cultured peripheral blood mononuclear cells (PBMC) in a donor-specific manner, independent of apoptosis. However, PBMC MIF production in children with acute malaria progressively declined with increasing anemia severity. Results presented here demonstrate that acquisition of hemozoin by monocytes is associated with suppression of peripheral blood MIF production and enhanced severity of anemia in childhood malaria.

Risk factors for childhood mortality in sub-Saharan Africa: A comparison of data from a Demographic and Health Survey and from a Demographic Surveillance System

Objects In a comparative analysis, the effect of risk factors for childhood mortality in Burkina Faso, sub-Saharan Africa, were computed from Demographic and Health Survey (DHS) and Demographic Surveillance System (DSS), two very different sources. While most analyses so far determined levels of risk factors, this analysis focuses on the effects of those risk factors. Methods Mortality levels are often calculated by strata of risk factor levels separately for each factor. In this publication, their effect was modelled jointly by survival analysis, using all-cause childhood mortality as outcome variable. All live births in rural Burkina Faso in the period of 1994–1998 recorded by the DHS survey Burkina Faso 1998–1999 (5018 births) and the Demographic Surveillance System based in Nouna, western Burkina Faso (6196 births) were included. Results A simultaneous estimation of hazard rate ratios by a Cox regression model yielded similar estimates for the DHS and DSS data, in line with previous findings based on the Nouna DSS alone. Although DHS surveys do not include children whose mothers had died, ignoring the strong risk factor “death of the mother” does not strongly affect DHS-based results. Conclusions Despite the different nature of survey (DHS) and longitudinal (DSS) data, these findings demonstrate that, despite some limitations, results derived from DHS surveys are broadly comparable to DSS data. Both are valuable tools for assessing the importance of risk factors for childhood mortality in sub-Saharan Africa, and they could be combined for better predictions.

P2.07: Risk factors for childhood mortality in sub‐Saharan Africa ‐ a comparison of survey data with form information from a demographic surveillance system

Biometrical JournalVolume 46, Issue S1 p. 125-125 Poster Sessions Abstracts P2.07: Risk factors for childhood mortality in sub-Saharan Africa - a comparison of survey data with form information from a demographic surveillance system Gaël P. Hammer, Gaël P. Hammer Gael.Hammer@urz.uni-heidelberg.de Search for more papers by this authorBocar Kouyaté, Bocar KouyatéSearch for more papers by this authorHeiko Becher, Heiko BecherSearch for more papers by this author Gaël P. Hammer, Gaël P. Hammer Gael.Hammer@urz.uni-heidelberg.de Search for more papers by this authorBocar Kouyaté, Bocar KouyatéSearch for more papers by this authorHeiko Becher, Heiko BecherSearch for more papers by this author First published: 17 March 2004 https://doi.org/10.1002/bimj.200490184AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume46, IssueS1Supplement: Abstracts of the Joint Meeting of the IBS‐DR and the DAEMarch 2004Pages 125-125 RelatedInformation

Variation in Toll-like receptor 4 and susceptibility to group A meningococcal meningitis in Gambian children.

Meningitis is an important cause of childhood mortality in sub-Saharan Africa. A case-control study investigating the role of the Toll-like receptor 4 gene in host susceptibility to Group A Neisseria meningitidis meningitis was conducted in 524 Gambian children. There was no association between a functional Toll-like receptor 4 gene polymorphism and meningitis, suggesting that this variant is not a major determinant of disease in this population.

Malaria and anemia.

Anemia due to infection is a major health problem in endemic areas for young children and pregnant women. The anemia is caused by excess removal of nonparasitized erythrocytes in addition to immune destruction of parasitized red cells, and impaired compensation for this loss by bone marrow dysfunction. The pathogenesis is complex, and a predominant mechanism has not been identified. Certain parasite and host characteristics may modify the anemia. Concomitant infections and nutritional deficiencies also contribute to anemia and may interact with the malarial infection. Few preventive strategies exist, and the management of severe malarial anemia with blood transfusion carries a risk of HIV transmission. The current increase in malaria-specific childhood mortality in sub-Saharan Africa attributed to drug-resistant infection is likely partly related to an increase in severe anemia. This review summarizes recent findings on the pathogenesis and epidemiology of malarial anemia.

Blood transfusion for severe anaemia in children in a Kenyan hospital

Severe anaemia often secondary to malaria is a major contributor to child mortality in sub-Saharan Africa. We have confirmed that use of simple clinical and laboratory criteria can identify those children likely to benefit most from treatment. We have also shown that the speed of response may be critical. The quality and capacity of blood transfusion services could therefore have a major, direct effect on inpatient child mortality.

Environmental factors, situation of women and child mortality in southwestern Nigeria

In an earlier paper, the author identified the role of maternal social characteristics on child mortality in Sub-Saharan Africa through statistical analysis ( Iyun, 1992; GeoJournal, 26(1), 43–52). This follow-up analysis attempts to further analyze and determine the relative significance of environmental and maternal factors on childhood mortality in two contrasting towns in southwestern Nigeria. The research design takes advantage of the integration of the medical and social sciences. The results of the current analysis reveal interesting insights into child mortality and maternal factors on one hand and domestic environmental conditions on the other. They give credence to an ecological perspective as a way to understand the complexities behind child survival. Domestic environmental conditions were stronger predictors of child mortality in the more developed study town, Ota, than the more traditional town, Iseyin. However, in both sites maternal factors, in particular age of mother at marriage, age of mother at first childbirth and parity were statistically significant predictors of child mortality. Mother’s education was only significant in the more urbanized center, and generally remains inconsistent in its relationship with child mortality. Furthermore, child mortality rates continued to be a function of an environmental factor, namely source of drinking water, and a child care behavior factor, where the child was kept when mother was at work, especially the market environment.

Lactic acidosis and oxygen debt in African children with severe anaemia.

A syndrome of severe anaemia (Hb < or = 5 g/dl), particularly severe malarial anaemia (SMA), remains a major cause of childhood mortality in sub-Saharan Africa. We hypothesized that the lactic acidosis which identifies those at the greatest risk of death often represents an oxygen debt incurred as a result of inadequate tissue perfusion. To examine this hypothesis, we measured oxygen consumption (VO2) using a portable metabolic monitor. Blood lactate and acid-base status were also determined. Pre-transfusion data on 44 children (28 with mild symptoms, 7 with respiratory distress and 9 controls) demonstrated very close dependence of VO2 on body surface area (BSA, R2 = 0.86, p < 0.001). After correcting for BSA, no significant differences were observed in mean VO2 values of the three clinical groups, indicating that a critical reduction in oxygen delivery is not the sole explanation for the development of a lactic acidosis and severe symptoms. Nine children (including five of the original 44) were monitored during transfusion. In four of the five with SMA, severe symptoms and severe lactic acidosis, transfusion produced a marked, transient increase in VO2 (maximum 30-41%), with a marked fall in blood lactate and clinical improvement. These data suggest that some children with SMA and respiratory distress accumulate an oxygen debt when a relatively high oxygen demand outstrips supply, this debt being repaid when supply is increased during transfusion. However, in the remaining one of these five children, an increase in VO2 (maximum 20%), was accompanied by a rise in blood lactate and clinical deterioration, suggesting that more pathophysiologically complex mechanisms, which may predominate in some children.

Does Foreign Capital Harm Poor Nations? New Estimates Based on Dixon and Boswell's Measures of Capital Penetration

L'A. s'efforce de mesurer l'impact economique de la penetration du capital et de l'investissement etranger sur l'economie des pays en voie de developpement. Il examine et critique le mode d'evaluation de la production propose par W. J. Dixon et T. Boswell. Il estime qu'il convient de distinguer investissement local et investissement etranger. Il presente les differents types d'interpretation et etudie un certain nombre de donnees collectees concernant le Panama, la Jamaique, le Liberia, la Guinee et enfin Trinidad et Tobago. Il se demande, d'une part, si l'investissement local et preferable a l'investissement etranger et, d'autre part, si ce dernier appauvrit les pays en voie de developpement. Il s'interroge sur le bien-fonde de la theorie de la dependance

Association of hepatitis B surface antigen carriage with severe malaria in Gambian children.

Severe malaria is a major cause of childhood mortality in sub-Saharan Africa but the factors predisposing children to severe forms of malaria have not been fully elucidated. In a case-control study of over 1,200 Gambian children hepatitis B virus carriage was significantly increased amongst cases of severe malaria compared to matched controls. We suggest that this association may relate to impaired clearance of liver stage parasites in the presence of the reduced level of HLA class I antigen expression on hepatocytes infected by hepatitis B virus. If this association is causal and viral carriage predisposes to severe malaria, widespread vaccination against hepatitis B virus may reduce mortality from severe malaria.

The impact of HIV-1 infection on mortality in children under 5 years of age in sub-Saharan Africa

To estimate the effects of the HIV-1 epidemic on mortality in children under 5 years of age in urban and rural populations in eastern and central, and southern Africa. A lifetable method that allows for the effects of competing causes (i.e., mortality due to HIV and other causes) was used to estimate mortality. Our calculations used published and unpublished data on HIV-1 infection in African adults and children (incidence and prevalence, vertical transmissions, transmission by blood transfusion and natural history), and typical baseline fertility and child mortality data. The results were applied to model rural and urban populations to explore the effects of parameters such as mortality in HIV-1-infected children, fertility in infected mothers and overall population growth. We estimate that child mortality will rise substantially because of the prevalence of HIV-1 in urban areas. There will be little difference in the absolute levels of increase in mortality between areas in eastern and central, and southern Africa with similar levels of HIV infection; however, in relative terms the effect will be more noticeable in southern Africa because of the lower baseline mortality. Towns with severe epidemics (30% adult seroprevalence) might experience a rise in child mortality of one-third in eastern and central Africa and three-quarters in southern Africa. This will cancel or reverse existing advantages in urban over rural levels of child mortality and this effect will be more pronounced in southern Africa. The exact impact of HIV-1 will vary according to mortality among HIV-1-infected children and to fertility among infected women. However, changes in age structure and population growth have relatively little impact on mortality. There are likely to be substantial increases in child mortality in sub-Saharan Africa as a result of HIV-1 infection. The main determinant of childhood infection is the scale of the epidemic among adults. Increases in mortality will depend on local adult seroprevalence but are hard to predict precisely because of possible variation in death rates among HIV-1-infected children. In rural areas with low seroprevalence other diseases will remain the main cause of mortality. However, in urban areas families and health services will have to face considerably increased demands from ill and dying children.

Health Transition in sub-Saharan Africa

The US National Academy of Sciences (NAS) National Research Council published a report on the effects of health programs on child mortality in sub-Saharan Africa which discusses the factors leading to the mortality decline that started around 1950 and continued throughout the 1980s and provides information on how to sustain this decline (but the report avoids far-reaching conclusions on the role of the health interventions). Child mortality (under age 5 years) has declined from about 290 to about 180 deaths/1000 live births from 1960 to 1985 but we do not know how much of this decline is attributable to biomedical causes to the Expanded Programme on Immunization to the Oral Rehydration Therapy program to the increased use of antibiotics to increased education to changes in nutrition or to improved water and sanitation. The NAS report presents the evidence of specific case studies on changes in mortality determinants but ignores the interventions of family planning and water and sanitation programs. Other ways to determine the effectiveness of interventions would be to analyze when health interventions were introduced and when they obtained substantial coverage and relate these dates to mortality decline or to compare demographic and health survey (DHS) data on key indicators between countries that are reasonably successful in delivering health interventions to those which are not; if the DHS data fail to support the success of the interventions then more effective interventions may be called for. A third method is to examine the mortality impact achieved in research projects. Important lessons from the NAS reports review of case studies (which takes national coverage levels into account to assess possible mortality impact) are 1) there is a dearth of information on integrated studies; 2) efficacy and effectiveness need to be distinguished; 3) lumping the results of a small number of longitudinal studies may not provide a picture applicable to most of the region; and 4) optimism about a single intervention based on a single study is often excessive. Although the NAS report fails to give age-specific mortality trends and differentials the attention they deserve it provides a useful and cautions review of the topic and suggests many avenues of needed research.