Beyond causes of death: The social determinants of mortality among children aged 1-59 months in Nigeria from 2009 to 2013

Abstract

Background: Millions of children worldwide suffer and die from conditions for which effective interventions exist. While there is ample evidence regarding these diseases, there is a dearth of information on the social factors associated with child mortality.

Methods: The 2014 Verbal and Social Autopsy Study was conducted based on a nationally representative sample of 3,254 deaths that occurred in children under the age of five and were reported on the birth history component of the 2013 Nigerian Demographic and Health Survey. We conducted a descriptive analysis of the preventive and curative care sought and obtained for the 2,057 children aged 1-59 months who died in Nigeria and performed regional (North vs. South) comparisons.

Results: A total of 1,616 children died in the northern region, while 441 children died in the South. The majority (72.5%) of deceased children in the northern region were born to mothers who had no education, married at a young age, and lived in the poorest two quintiles of households. When caregivers first noticed that their child was ill, a median of 2 days passed before they sought or attempted to seek healthcare for their children. The proportion of children who reached and departed from their first formal healthcare provider alive was greater in the North (30.6%) than in the South (17.9%) (p<0.001). A total of 548 children were moderately or severely sick at discharge from the first healthcare provider, yet only 3.9%-18.1% were referred to a second healthcare provider. Cost, lack of transportation, and distance from healthcare facilities were the most commonly reported barriers to formal care-seeking behavior.

Conclusions: Maternal, household, and healthcare system factors contributed to child mortality in Nigeria. Information regarding modifiable social factors may be useful in planning intervention programs to promote child survival in Nigeria and other low-income countries in sub-Saharan Africa.

Fig 1. Coverage along the continuum of care for young children in Nigeria, from 2009–2013.

Notes: *: Proportion of children who were NOT usually beside or carried by their mother when she cooked inside the home. **: Insecticide-treated bed net. ***: Children whose fatal illness started at 0–23 months and satisfied either of the following conditions: (i) Child’s illness began before 6 months of age (0–5 months), he/she was being breastfed at the time of fatal illness and was not given anything but breast; (ii) Breastfed children whose fatal illness started at 6–8 months old and 9–23 months old who received, respectively, at least two and three complementary non-liquid feedings each day; (iii) Child's fatal illness started at 6–23 months old and he/she received at least four replacement feeds each day (including milk and solid, semi-solid and soft foods) milk as food. ****Information on immunizations was obtained either from the vaccination card or when there was no written record, from the respondent (mainly the mother). Polio0 is the Polio vaccination given at birth; Fully Immunized children received BCG, measles, and three doses each of DPT/PENTA and polio vaccine (excluding polio vaccine given at birth).

Fig 2. The “Pathway to Survival” component and indicators.

Fig 3. Perceived illness severity at illness onset by care-seeking patterns, Nigeria 2009–2013.

Fig 4. Illness severity ranking at onset and at decision to seek care among children for whom caregivers tried to seek or sought some formal care (N = 1293*), by region, Nigeria 2009–2013.

Note: *5 children had missing information that did not allow their illness severity ranking.

Fig 5. Type of first formal health provider reached by caregivers with their ill children.

Fig 6. Decision of first healthcare provider for children moderately or severely sick at discharge (N = 548), by health facility/provider.

Fig 7. Main care-seeking constraints for child deaths (N = 1969).