Prioritizing Health Care Strategies to Reduce Childhood Mortality

Abstract

Importance: Although child mortality trends have decreased worldwide, deaths among children younger than 5 years of age remain high and disproportionately circumscribed to sub-Saharan Africa and Southern Asia. Tailored and innovative approaches are needed to increase access, coverage, and quality of child health care services to reduce mortality, but an understanding of health system deficiencies that may have the greatest impact on mortality among children younger than 5 years is lacking.

Objective: To investigate which health care and public health improvements could have prevented the most stillbirths and deaths in children younger than 5 years using data from the Child Health and Mortality Prevention Surveillance (CHAMPS) network.

Design, setting, and participants: This cross-sectional study used longitudinal, population-based, and mortality surveillance data collected by CHAMPS to understand preventable causes of death. Overall, 3390 eligible deaths across all 7 CHAMPS sites (Bangladesh, Ethiopia, Kenya, Mali, Mozambique, Sierra Leone, and South Africa) between December 9, 2016, and December 31, 2021 (1190 stillbirths, 1340 neonatal deaths, 860 infant and child deaths), were included. Deaths were investigated using minimally invasive tissue sampling (MITS), a postmortem approach using biopsy needles for sampling key organs and fluids.

Main outcomes and measures: For each death, an expert multidisciplinary panel reviewed case data to determine the plausible pathway and causes of death. If the death was deemed preventable, the panel identified which of 10 predetermined health system gaps could have prevented the death. The health system improvements that could have prevented the most deaths were evaluated for each age group: stillbirths, neonatal deaths (aged <28 days), and infant and child deaths (aged 1 month to <5 years).

Results: Of 3390 deaths, 1505 (44.4%) were female and 1880 (55.5%) were male; sex was not recorded for 5 deaths. Of all deaths, 3045 (89.8%) occurred in a healthcare facility and 344 (11.9%) in the community. Overall, 2607 (76.9%) were deemed potentially preventable: 883 of 1190 stillbirths (74.2%), 1010 of 1340 neonatal deaths (75.4%), and 714 of 860 infant and child deaths (83.0%). Recommended measures to prevent deaths were improvements in antenatal and obstetric care (recommended for 588 of 1190 stillbirths [49.4%], 496 of 1340 neonatal deaths [37.0%]), clinical management and quality of care (stillbirths, 280 [23.5%]; neonates, 498 [37.2%]; infants and children, 393 of 860 [45.7%]), health-seeking behavior (infants and children, 237 [27.6%]), and health education (infants and children, 262 [30.5%]).

Conclusions and relevance: In this cross-sectional study, interventions prioritizing antenatal, intrapartum, and postnatal care could have prevented the most deaths among children younger than 5 years because 75% of deaths among children younger than 5 were stillbirths and neonatal deaths. Measures to reduce mortality in this population should prioritize improving existing systems, such as better access to antenatal care, implementation of standardized clinical protocols, and public education campaigns.

Figure 1.. Number of Deaths Deemed Preventable Across All Sites by Age Group, December 2016 to December 2021

A total of 3390 deaths were included. Nonconsensus indicates that the expert panel was unable to agree as to whether the death could have been prevented. Whiskers indicate 95% CIs.

Figure 2.. Proportion of 3390 Deaths That Could Have Been Prevented for Each Health System Improvement Category Across All Sites by Age Group, December 2016 to December 2021

This figure assumes (1) all recommendations given for a single death are necessary to prevent that death, (2) for every category implemented for deaths with multiple categories, deaths would be reduced proportionally, and (3) any single category among all categories recommended for each death is sufficient to prevent that death. Categories appear in the Table. ANC indicates antenatal care.

Figure 3.. Cumulative Number of Deaths Over Time and Hypothetical Reduction in Deaths From Implementing Optimal Combinations of 1 to 10 Health System Improvement Categories Across All Sites by Age Group, December 2016 to December 2021

This figure assumes all recommendations given for a single death are necessary to prevent that death. None indicates no health system improvements and represents the actual number of deaths over time. 1 indicates improved clinical management and quality of care; 2, improved antenatal and obstetric care and management; 3, improved health-seeking behavior; 4, improved infection prevention and control; 5, improved health education, eg, immunizations, preventing malnutrition, diarrhea, malaria, burns, poisoning; 6, improved nutritional support; 7, improved HIV prevention and control; 8, improved family planning; 9, improved use of existing vaccinations; and 10, improved transport system.