Alain K. Koffi

Social autopsy study identifies determinants of neonatal mortality in Doume, Nguelemendouka and Abong–Mbang health districts, Eastern Region of Cameroon

Background Reducing preventable medical causes of neonatal death for faster progress toward the MGD4 will require Cameroon to adequately address the social factors contributing to these deaths. The objective of this paper is to explore the social, behavioral and health systems determinants of newborn death in Doume, Nguelemendouka and Abong–Mbang health districts, in Eastern Region of Cameroon, from 2007–2010. Methods Data come from the 2012 Verbal/Social Autopsy (VASA) study, which aimed to determine the biological causes and social, behavioral and health systems determinants of under–five deaths in Doume, Nguelemendouka and Abong–Mbang health districts in Eastern Region of Cameroon. The analysis of the data was guided by the review of the coverage of key interventions along the continuum of normal maternal and newborn care and by the description of breakdowns in the care provided for severe neonatal illnesses within the Pathway to Survival conceptual framework. Results One hundred sixty–four newborn deaths were confirmed from the VASA survey. The majority of the deceased newborns were living in households with poor socio–economic conditions. Most (60–80%) neonates were born to mothers who had one or more pregnancy or labor and delivery complications. Only 23% of the deceased newborns benefited from hygienic cord care after birth. Half received appropriate thermal care and only 6% were breastfed within one hour after birth. Sixty percent of the deaths occurred during the first day of life. Fifty–five percent of the babies were born at home. More than half of the deaths (57%) occurred at home. Of the 64 neonates born at a health facility, about 63% died in the health facility without leaving. Careseeking was delayed for several neonates who became sick after the first week of life and whose illnesses were less serious at the onset until they became more severely ill. Cost, including for transport, health care and other expenses, emerged as main barriers to formal care–seeking both for the mothers and their newborns. Conclusions This study presents an opportunity to strengthen maternal and newborn health by increasing the coverage of essential and low cost interventions that could have saved the lives of many newborns in eastern Cameroon.

Factors associated with delay in care-seeking for fatal neonatal illness in the Sylhet district of Bangladesh: results from a verbal and social autopsy study.

Background We conducted a social and verbal autopsy study to determine cultural–, social– and health system–related factors that were associated with the delay in formal care seeking in Sylhet district, Bangladesh. Methods Verbal and social autopsy interviews were conducted with mothers who experienced a neonatal death between October 2007 and May 2011. We fitted a semi–parametric regression model of the cumulative incidence of seeking formal care first, accounting for competing events of death or seeking informal care first. Results Three hundred and thirty–one neonatal deaths were included in the analysis and of these, 91(27.5%) sought formal care first; 26 (7.9%) sought informal care first; 59 (17.8%) sought informal care only, and 155 (46.8%) did not seek any type of care. There was lower cumulative incidence of seeking formal care first for preterm neonates (sub–hazard ratio SHR 0.61, P = 0.025), and those who delivered at home (SHR 0.52, P = 0.010); and higher cumulative incidence for those who reported less than normal activity (SHR 1.95, P = 0.048). The main barriers to seeking formal care reported by 165 mothers included cost (n = 98, 59.4%), believing the neonate was going to die anyway (n = 29, 17.7%), and believing traditional care was more appropriate (n = 26, 15.8%). Conclusions The majority of neonates died before formal care could be sought, but formal care was more likely to be sought than informal care. There were economic and social belief barriers to care–seeking. There is a need for programs that educate caregivers about well–recognized danger signs requiring timely care–seeking, particularly for preterm neonates and those who deliver at home.

Social determinants of child mortality in Niger: Results from the 2012 National Verbal and Social Autopsy Study.

Background Understanding the determinants of preventable deaths of children under the age of five is important for accelerated annual declines – even as countries achieve the UN’s Millennium Development Goals and the target date of 2015 has been reached. While research has documented the extent and nature of the overall rapid decline in child mortality in Niger, there is less clear evidence to provide insight into the contributors to such deaths. This issue is the central focus of this paper. Methods We analyzed a nationally representative cross–sectional sample of 620 child deaths from the 2012 Niger Verbal Autopsy/Social Autopsy (VASA) Survey. We conducted a descriptive analysis of the data on preventive and curative care, guided by the coverage of proven indicators along the continuum of well child care and illness recognition and care–seeking for child illnesses encompassed by the BASICS/CDC Pathway to Survival model. Results Six hundred twenty deaths of children (1–59 months of age) were confirmed from the VASA survey. The majority of these children lived in households with precarious socio–economic conditions. Among the 414 children whose fatal illnesses began at age 0–23 months, just 24.4% were appropriately fed. About 24% of children aged 12–59 months were fully immunized. Of 601 children tracked through the Pathway to Survival, 62.4% could reach the first health care provider after about 67 minutes travel time. Of the 306 children who left the first health care provider alive, 161 (52.6%) were not referred for further care nor received any home care recommendations, and just 19% were referred to a second provider. About 113 of the caregivers reported cost (35%), distance (35%) and lack of transport (30%) as constraints to care–seeking at a health facility. Conclusion Despite Niger’s recent major achievements in reducing child mortality, the following determinants are crucial to continue building on the gains the country has made: improved socio–economic state of the poor in the country, investment in women’s education, adoption of the a law to prevent marriage of young girls before 18 years of age, and implementation of health programs that encourage breastfeeding and complementary feeding, immunization, illness recognition, prompt and appropriate care–seeking, and improved referral rates.

Community health worker programmes after the 2013–2016 Ebola outbreak

The 2013–2016 Ebola virus disease outbreak in West Africa exposed an urgent need to strengthen health surveillance and health systems in low-income countries, not only to improve the health of populations served by these health systems but also to promote global health security.1 Chronically fragile and under-resourced health systems2 enabled the initial outbreak in Guinea to spiral into an epidemic of over 28 616 cases and 11 310 deaths (as of 5 May 2016)3 in Guinea, Liberia and Sierra Leone, requiring an unprecedented global response that is still ongoing. Control efforts were hindered by gaps in the formal health system and by resistance from the community, fuelled by fear and poor communication. Lessons learnt from this Ebola outbreak have raised the question of how the affected countries, and other low-income countries with similarly weak health systems, can build stronger health systems and surveillance mechanisms to prevent future outbreaks from escalating.4 Factors that were important in the growth and persistence of the Ebola virus outbreak were lack of trust in the health system at the community level, the spread of misinformation, deeply embedded cultural practices conducive to transmission (e.g. burial customs), inadequate reporting of health events and the public’s lack of access to health services.1 Community health workers are in a unique position to mitigate these factors through surveillance for danger signs and mobilization of communities when an outbreak has been identified. In this paper we make the case for investing in robust national community health worker programmes as one of the strategies for improving global health security, for preventing future catastrophic infectious disease outbreaks and for strengthening health systems.

Direct estimates of national neonatal and child cause-specific mortality proportions in Niger by expert algorithm and physician-coded analysis of verbal autopsy interviews

Background This study was one of a set of verbal autopsy investigations undertaken by the WHO/UNCEF–supported Child Health Epidemiology Reference Group (CHERG) to derive direct estimates of the causes of neonatal and child deaths in high priority countries of sub–Saharan Africa. The objective of the study was to determine the cause distributions of neonatal (0–27 days) and child (1–59 months) mortality in Niger. Methods Verbal autopsy interviews were conducted of random samples of 453 neonatal deaths and 620 child deaths from 2007 to 2010 identified by the 2011 Niger National Mortality Survey. The cause of each death was assigned using two methods: computerized expert algorithms arranged in a hierarchy and physician completion of a death certificate for each child. The findings of the two methods were compared to each other, and plausibility checks were conducted to assess which is the preferred method. Comparison of some direct measures from this study with CHERG modeled cause of death estimates are discussed. Findings The cause distributions of neonatal deaths as determined by expert algorithms and the physician were similar, with the same top three causes by both methods and all but two other causes within one rank of each other. Although child causes of death differed more, the reasons often could be discerned by analyzing algorithmic criteria alongside the physician’s application of required minimal diagnostic criteria. Including all algorithmic (primary and co–morbid) and physician (direct, underlying and contributing) diagnoses in the comparison minimized the differences, with kappa coefficients greater than 0.40 for five of 11 neonatal diagnoses and nine of 13 child diagnoses. By algorithmic diagnosis, early onset neonatal infection was significantly associated (χ2 = 13.2, P < 0.001) with maternal infection, and the geographic distribution of child meningitis deaths closely corresponded with that for meningitis surveillance cases and deaths. Conclusions Verbal autopsy conducted in the context of a national mortality survey can provide useful estimates of the cause distributions of neonatal and child deaths. While the current study found reasonable agreement between the expert algorithm and physician analyses, it also demonstrated greater plausibility for two algorithmic diagnoses and validation work is needed to ascertain the findings. Direct, large–scale measurement of causes of death complement, can strengthen, and in some settings may be preferred over modeled estimates.

Verbal/Social Autopsy in Niger 2012-2013: A new tool for a better understanding of the neonatal and child mortality situation

Niger, one of the poorest countries in the world, recently used for the first time the integrated verbal and social autopsy (VASA) tool to assess the biological causes and social and health system determinants of neonatal and child deaths. These notes summarize the Nigerien experience in the use of this new tool, the steps taken for high level engagement of the Niger government and stakeholders for the wide dissemination of the study results and their use to support policy development and maternal, neonatal and child health programming in the country. The experience in Niger reflects lessons learned by other developing countries in strengthening the use of data for evidence–based decision making, and highlights the need for the global health community to provide continued support to country data initiatives, including the collection, analysis, interpretation and utilization of high quality data for the development of targeted, highly effective interventions. In Niger, this is supporting the country’s progress toward achieving Millennium Development Goal 4. A follow–up VASA study is being planned and the tool is being integrated into the National Health Management Information System. VASA studies have now been completed or are under way in additional sub–Saharan African countries, in each through the same collaborative process used in Niger to bring together health policy makers, program planners and development partners.

Verbal/social autopsy study helps explain the lack of decrease in neonatal mortality in Niger, 2007–2010

Background This study was one of a set of verbal/social autopsy (VASA) investigations undertaken by the WHO/UNICEF–supported Child Health Epidemiology Reference Group to estimate the causes and determinants of neonatal and child deaths in high priority countries. The study objective was to help explain the lack of decrease in neonatal mortality in Niger from 2007 to 2010, a period during which child mortality was decreasing. Methods VASA interviews were conducted of a random sample of 453 neonatal deaths identified by the 2010 Niger National Mortality Survey (NNMS). Causes of death were determined by expert algorithm analysis, and the prevalence of household, community and health system determinants were examined along the continuum of maternal and newborn care, the Pathway to Survival for newborn illnesses, and an extended pathway for maternal complications. The social autopsy findings were compared to available data for survivors from the same cohort collected by the NNMS and the 2012 Niger Demographic and Health Survey. Findings Severe neonatal infection and birth asphyxia were the leading causes of early neonatal death in the community and facilities. Death in the community after delayed careseeking for severe infection predominated during the late neonatal period. The levels of nearly all demographic, antenatal and delivery care factors were in the direction of risk for the VASA study decedents. They more often resided rurally (P < 0.001) and their mothers were less educated (P = 0.03) and gave birth when younger (P = 0.03) than survivors’ mothers. Their mothers also were less likely to receive quality antenatal care (P < 0.001), skilled attendance at birth (P = 0.03) or to deliver in an institution (P < 0.001). Nearly half suffered an obstetric complication, with more maternal infection (17.9% vs 0.2%), antepartum hemorrhage (12.5% vs 0.5%) and eclampsia/preeclampsia (9.5% vs 1.6%) than for all births in Niger. Their mothers also were unlikely to seek health care for their own complications (37% to 42%) as well as for the newborn’s illness (30.6%). Conclusions Niger should scale up its recently implemented package of high–impact interventions to additional integrated health facilities and expand the package to provide antenatal care and management of labor and delivery, with support to reach a higher level facility when required. Community interventions are needed to improve illness recognition and careseeking for severe neonatal infection.

Strengthening Community Networks for Vital Event Reporting: Community-Based Reporting of Vital Events in Rural Mali

Background Like many developing countries, Mali has few sources of mortality data. High quality mortality estimates are available from household surveys, such as the demographic and health surveys (DHS), approximately every five years, making it difficult to track progress in reducing mortality. The Rapid Mortality Monitoring (RMM) project in Mali aimed to address this issue by testing a community-based approach to measuring under-five mortality on a yearly basis. Methods and Findings Seventy-eight community-based workers (relais) were identified in 20 villages comprising approximately 5,300 households. The relais reported pregnancies, births, and under-five deaths from July, 2012 to November, 2013. Data were double-entered, reconciled, cleaned, and analyzed monthly. In November-December 2013, we administered a full pregnancy history (FPH) to women of reproductive age in a census of the households in the project villages. We assessed the completeness of the counts of births and deaths, and the validity of under-five, infant, and neonatal mortality rates from the community-based method against the retrospective FPH for two rolling twelve-month periods. Monthly reporting by relais was high, with reports on pregnancies, births, and deaths consistently provided from all 78 relais catchment areas. Relais reported 1,660 live births and 276 under-five deaths from July, 2012 to November, 2013. The under-five mortality rate calculated from the relais data was similar to that estimated using the validation survey, where the overall ratios of the community-based to FPH-based mortality rates for the reporting periods were 100.4 (95% CI: 80.4, 120.5) and 100.8 (95% CI: 79.5, 122.0). Conclusions On a small scale, the community-based method in Mali produced estimates of annualized under-five mortality rates that were consistent with those obtained from a FPH. The community-based method should be considered for scale-up in Mali, with appropriate measures to ensure community engagement, data quality, and cross-validation with comparable FPHs.

Understanding misclassification between neonatal deaths and stillbirths: Empirical evidence from Malawi

Improving the counting of stillbirths and neonatal deaths is important to tracking Sustainable Development Goal 3.2 and improving vital statistics in low- and middle-income countries (LMICs). However, the validity of self-reported stillbirths and neonatal deaths in surveys is often threatened by misclassification errors between the two birth outcomes. We assessed the extent and correlates of stillbirths being misclassified as neonatal deaths by comparing two recent and linked population surveys conducted in Malawi, one being a full birth history (FBH) survey, and the other a follow-up verbal/social autopsy (VASA) survey. We found that one-fifth of 365 neonatal deaths identified in the FBH survey were classified as stillbirths in the VASA survey. Neonatal deaths with signs of movements in the last few days before delivery reported were less likely to be misclassified stillbirths (OR = 0.08, p<0.05). Having signs of birth injury was found to be associated with higher odds of misclassification (OR = 6.17, p<0.05). We recommend replicating our study with larger sample size in other settings. Additionally, we recommend conducting validation studies to confirm accuracy and completeness of live births and neonatal deaths reported in household surveys with events reported in a full birth history and the extent of underestimation of neonatal mortality resulting from misclassifications. Questions on fetal movement, signs of life at delivery and improved probing among older mother may be useful to improve accuracy of reported events.

Social autopsy of neonatal mortality suggests needed improvements in maternal and neonatal interventions in Balaka and Salima districts of Malawi.

Background The Every Newborn Action Plan calls for reducing the neonatal mortality rates to fewer than 10 deaths per 1000 live births in all countries by 2035. The current study aims to increase our understanding of the social and modifiable factors that can be addressed or reinforced to improve and accelerate the decline in neonatal mortality in Malawi. Methods The data come from the 2013 Verbal and Social Autopsy (VASA) study that collected data in order to describe the biological causes and the social determinants of deaths of children under 5 years of age in Balaka and Salima districts of Malawi. This paper analyses the social autopsy data of the neonatal deaths and presents results of a review of the coverage of key interventions along the continuum of normal maternal and newborn care and the description of breakdowns in the care provided for neonatal illnesses within the Pathway to Survival framework. Results A total of 320 neonatal deaths were confirmed from the VASA survey. While one antenatal care (ANC) visit was high at 94%, the recommended four ANC visits was much lower at 41% and just 17% of the mothers had their urines tested during the pregnancy. 173 (54%) mothers of the deceased newborns had at least one labor/delivery complication that began at home. The caregivers of 65% (n = 75) of the 180 newborns that were born at home or born and left a health facility alive perceived them to be severely ill at the onset of their illness, yet only 44% (n = 80) attempted and 36% (n = 65)could reach the first health provider after an average of 91 minutes travel time. Distance, lack of transport and cost emerged as the most important constraints to formal care–seeking during delivery and during the newborn fatal illness. Conclusions This study suggests that maternal and neonatal health organizations and the local government of Malawi should increase the demand for key maternal and child health interventions, including the recommended 4 ANC visits, and ensure urine screening for all pregnant women. Early recognition and referrals of women with obstetric complications and interventions to promote maternal recognition of neonatal illnesses and care–seeking before the child becomes severely ill are also needed to improve newborn survival in Balaka and Salima districts of Malawi.