Linnea Zimmerman

Mortality risks in children aged 5–14 years in low-income and middle-income countries: a systematic empirical analysis

BACKGROUND Health priorities since the UN Millennium Declaration have focused strongly on children younger than 5 years. The health of older children (age 5-9 years) and younger adolescents (age 10-14 years) has been neglected until recently, especially in low-income and middle-income countries, and mortality measures for these age groups have often been derived from overly flexible models. We report global and regional empirical mortality estimates for children aged 5-14 years in low-income and middle-income countries, and compare them with ones from existing models. METHODS For this empirical analysis, we obtained birth-history data from surveys done over a 25-year period from 1986 by the Demographic and Health Surveys programme for 84 World Bank low-income and middle-income countries, and data about household deaths in China from their 1990 and 2010 censuses. We used these data to calculate mortality risks for children aged 5-14 years, and compare these risks to corresponding estimates of mortality in children younger than 5 years in the same countries. We used regression analysis to model these associations, generate estimates of the risks, and derive estimates of the numbers of deaths for 1990 and 2010 by applying those risks to population estimates from the UN World Population Prospects (WPP) 2012 Revision. We then compared the numbers of deaths with those given by the UN WPP itself and by the Institute for Health Metrics and Evaluations Global Burden of Disease (GBD) 2010 study. FINDINGS The mean risk of a child dying at age 5-14 years in low-income and middle-income countries is about 19% of the risk of dying between birth and age 5 years (12% at age 5-9 plus 7% at age 10-14). According to our estimates, the total number of deaths at ages 5-14 years in low-income and middle-income regions fell from about 2·4 million (95% CI 1·9-2·7) in 1990 to about 1·5 million (1·2-1·8) in 2010. From our estimates we concluded there to have been 200,000 (16%) more deaths at ages 5-14 than in the UN report; however, our estimates exceeded GBD estimates by more than 700,000 (87%). The average annual rate of decline in mortality at age 5-9 years (about 3%) slightly exceeded that for ages 0-4 years (2·8%), but progress has been slower for age 10-14 years (about 2%). INTERPRETATION Our analysis suggests that mortality risks nowadays in the age range 5-14 years in low-income and middle-income countries are rather higher (relative to mortality in children younger than 5 years) than would be expected on the basis of historical evidence. Our findings broadly lend support for the UN WPP mortality estimates, but are almost double those underpinning GBD 2010. Global policy emphasis on reduction of mortality in children younger than 5 years should be broadened to include older children and adolescents. FUNDING The Lancet Commission on Investing in Health and the Bill & Melinda Gates Foundation.

Potential gains in reproductive-aged life expectancy by eliminating maternal mortality: A demographic bonus of achieving MDG 5

Objective We assessed the change over time in the contribution of maternal mortality to a life expectancy calculated between ages 15 and 49, or Reproductive-Aged Life Expectancy (RALE). Our goal was to estimate the increase in RALE in developed countries over the twentieth century and the hypothetical gains in African countries today by eliminating maternal mortality. Methods Analogous to life expectancy, RALE is calculated from a life table of ages 15 to 49. Specifically, RALE is the average number of years that women at age 15 would be expected to live between 15 and 49 with current mortality rates. Associated single decrement life tables of causes of death other than maternal mortality are explored to assess the possible gains in RALE by reducing or eliminating maternal mortality. We used population-based data from the Human Mortality Database and the Demographic and Health Surveys. Findings In developed countries, five years in RALE were gained over the twentieth century, of which approximately 10%, or half a year, was attributable to reductions in maternal mortality. In sub-Saharan African countries, the possible achievable gains fluctuate between 0.24 and 1.47 years, or 6% and 44% of potential gains in RALE. Conclusions Maternal mortality is a rare event, yet it is still a very important component of RALE. Averting the burden of maternal deaths could return a significant increase in the most productive ages of human life.

PMA2020: Rapid Turn-Around Survey Data to Monitor Family Planning Service and Practice in Ten Countries: PMA2020: Rapid Turn-Around Survey Data

In 2012, the London Summit on Family Planning adopted the ambitious goal of increasing access to contraception for 120 million additional women and girls in the world’s poorest countries by 2020. Family Planning 2020 (FP2020)1 was established as a coordinating body to monitor progress. In order to monitor country progress and to change course in the event of stagnating or declining use, data were needed more frequently and more quickly than data provided by typical surveys. Performance Monitoring and Accountability 2020 (PMA2020) was created to provide rapid and frequent estimates of modern contraceptive use in FP2020 priority countries. Currently operational in ten countries (Burkina Faso, DRC, Ethiopia, Ghana, India, Indonesia, Kenya, Niger, Nigeria, and Uganda), PMA2020 conducts surveys every six months to one year, providing FP2020, governments, and other stakeholders frequent information on contraceptive use, demand, and supply that can inform policies and programs and identify areas for improvement. PMA2020 recruits women from within or near selected enumerations areas (EAs) and trains them in collecting household and facility-level data using smartphones and submitting the data to a cloud server. These resident enumerators (REs) are then deployed to collect data on a repeated basis—each round within a six-week period—with refresher training between each round. Household data include information on household members, as well as assets, livestock ownership, housing construction, and water, sanitation, and hygiene (WASH) conditions. Women aged 15–49 who are either usual members of the household or who slept in the

Progress and inequities in maternal mortality in Afghanistan (RAMOS-II): a retrospective observational study

BACKGROUND The risk of maternal death in Afghanistan is among the highest in the world; however, the risks within the country are poorly understood. Subnational maternal mortality estimates are needed along with a broader understanding of determinants to guide future maternal health programmes. Here we aimed to study maternal mortality risk and causes, care-seeking patterns, and costs within the country. METHODS We did a household survey (RAMOS-II) in the urban area of Kabul city and the rural area of Ragh, Badakshan. Questionnaires were administered to senior female household members and data were collected by a team of female interviewers with secondary school education. Information was collected about all deaths, livebirths, stillbirths, health-care access and costs, household income, and assets. Births were documented using a pregnancy history. We investigated all deaths in women of reproductive age (12-49 years) since January, 2008, using verbal autopsy. Community members; service providers; and district, provincial, and national officials in each district were interviewed to elicit perceptions of changes in maternal mortality risk and health service provision, along with programme and policy documentation of maternal care coverage. FINDINGS Data were collected between March 2, 2011, and Oct 16, 2011, from 130 688 participants: 63 329 in Kabul and 67 359 in Ragh. The maternal mortality ratio in Ragh was quadruple that in Kabul (713 per 100 000 livebirths, 95% CI 553-873 in Ragh vs 166, 63-270 in Kabul). We recorded similar patterns for all other maternal death indicators, including the maternal mortality rate (1·7 per 1000 women of reproductive age, 95% CI 1·3-2·1 in Ragh vs 0·2, 0·1-0·3 in Kabul). Infant mortality also differed significantly between the two areas (115·5 per 1000 livebirths, 95% CI 108·6-122·3 in Ragh vs 24·8, 20·5-29·0 in Kabul). In Kabul, 5594 (82%) of 6789 women reported a skilled attendant during recent deliveries compared with 381 (3%) of 11 366 women in Ragh. An estimated 85% of women in Kabul and 47% in Ragh incurred delivery costs (mean US

Monitoring Change in Child Mortality through Household Surveys.

66·20, IQR

The Relationship between Household Sanitation and Women’s Experience of Menstrual Hygiene: Findings from a Cross-Sectional Survey in Kaduna State, Nigeria

61·30 in Kabul and

Measuring family planning quality and its link with contraceptive use in public facilities in Burkina Faso, Ethiopia, Kenya and Uganda.

9·89,

Transitions into puberty and access to sexual and reproductive health information in two humanitarian settings: a cross-sectional survey of very young adolescents from Somalia and Myanmar

11·87 in Ragh). Maternal complications were the third leading cause of death in women of reproductive age in Kabul, and the leading cause in Ragh, and were mainly due to hypertensive diseases of pregnancy. The maternal mortality rate decreased significantly between 2002 and 2011 in both Kabul (by 71%) and Ragh (by 84%), plus all other maternal mortality indicators in Ragh. INTERPRETATION Remarkable maternal and other mortality reductions have occurred in Afghanistan, but the disparity between urban and rural sites is alarming, with all maternal mortality indicators significantly higher in Ragh than in Kabul. Customised service delivery is needed to ensure parity for different geographic and security settings. FUNDING United States Agency for International Development (USAID).

Accelerating and improving survey implementation with mobile technology: Lessons from PMA2020 implementation in Lagos, Nigeria

Background Most low- and middle-income countries lack fully functional civil registration systems. Measures of under-five mortality are typically derived from periodic household surveys collecting detailed information from women on births and child deaths. However, such surveys are expensive and are not appropriate for monitoring short-term changes in child mortality. We explored and tested the validity of two new analysis methods for less-expensive summary histories of births and child deaths for such monitoring in five African countries. Methods and Findings The first method we explored uses individual-level survey data on births and child deaths to impute full birth histories from an earlier survey onto summary histories from a more recent survey. The second method uses cohort changes between two surveys in the average number of children born and the number of children dead by single year of age to estimate under-five mortality for the inter-survey period. The first method produces acceptable annual estimates of under-five mortality for two out of six applications to available data sets; the second method produced an acceptable estimate in only one of five applications, though none of the applications used ideal data sets. Conclusions The methods we tested were not able to produce consistently good quality estimates of annual under-five mortality from summary birth history data. The key problem we identified was not with the methods themselves, but with the underlying quality of the summary birth histories. If summary birth histories are to be included in general household surveys, considerable emphasis must be placed on quality control.

Understanding the unique experiences, perspectives and sexual and reproductive health needs of very young adolescents: Somali refugees in Ethiopia

Global efforts to improve sanitation have emphasized the needs of women and girls. Managing menstruation is one such need, yet there is scarce research capturing current practices. This study investigated the relationships between household sanitation and women’s experience of menstrual management. Secondary analyses were undertaken on data from 1994 women and girls collected through the Performance Monitoring and Accountability 2020 survey in Kaduna, Nigeria. In multivariable models, women had higher odds of using the main household sanitation facility for menstrual management when they had access to a basic (OR = 1.76 95%CI 1.26–2.46) or limited (OR = 1.63 95%CI 1.08–2.48) sanitation facility, compared to an unimproved facility. Women with no household sanitation facility had higher odds of using their sleeping area (OR = 3.56 95%CI 2.50–5.06) or having no facility for menstrual management (OR = 9.86 95%CI 5.76–16.87) than women with an unimproved sanitation facility. Menstrual management locations were associated with ratings of their characteristics. Safely managed or basic sanitation facilities were not rated more favorably than unimproved facilities in privacy (OR = 1.02 95%CI 0.70–1.48), safety (OR = 1.45 95%CI 0.98–2.15), access to a lock (OR = 0.93 95%CI 0.62–1.37), or soap and water (OR = 1.04 95%CI 0.70–1.56). Women using their sleeping area had more favorable perceptions of their environment. Findings suggest household sanitation influences women’s choices for menstrual management, but that existing indicators for improvement are not sensitive to menstrual needs.