Causes of death identified in neonates enrolled through Child Health and Mortality Prevention Surveillance (CHAMPS), December 2016 -December 2021

Abstract

Each year, 2.4 million children die within their first month of life. Child Health and Mortality Prevention Surveillance (CHAMPS) established in 7 countries aims to generate accurate data on why such deaths occur and inform prevention strategies. Neonatal deaths that occurred between December 2016 and December 2021 were investigated with MITS within 24-72 hours of death. Testing included blood, cerebrospinal fluid and lung cultures, multi-pathogen PCR on blood, CSF, nasopharyngeal swabs and lung tissue, and histopathology examination of lung, liver and brain. Data collection included clinical record review and family interview using standardized verbal autopsy. The full set of data was reviewed by local experts using a standardized process (Determination of Cause of Death) to identify all relevant conditions leading to death (causal chain), per WHO recommendations. For analysis we stratified neonatal death into 24-hours of birth, early (1-<7 days) and late (7-<28 days) neonatal deaths. We analyzed 1458 deaths, 41% occurring within 24-hours, 41% early and 18% late neonatal deaths. Leading underlying causes of death were complications of intrapartum events (31%), complications of prematurity (28%), infections (17%), respiratory disorders (11%), and congenital malformations (8%). In addition to the underlying cause, 62% of deaths had additional conditions and 14% had ≥3 other conditions in the causal chain. The most common causes considering the whole causal chain were infection (40%), prematurity (32%) and respiratory distress syndrome (28%). Common maternal conditions linked to neonatal death were maternal hypertension (10%), labour and delivery complications (8%), multiple gestation (7%), placental complications (6%) obstructed labour and chorioamnionitis (5%, each). CHAMPS' findings showing the full causal chain of events that lead to death, in addition to maternal factors, highlights the complexities involved in each death along with the multiple opportunities for prevention. Highlighting improvements to prenatal and obstetric care and infection prevention are urgently needed in high-mortality settings.

Fig 1. Flowchart of enrolled neonatal deaths from CHAMPS sites between December 2016 –December 2021, that had minimally invasive tissue samples (MITS) and consent only for verbal autopsy and clinical abstraction (Non-MITS) and included in the analysis.

Fig 2. Relative proportion of neonatal deaths enrolled in CHAMPS, 2017–2021, attributed to the 5 most common categories of underlying causes (n = 826), overall and for deaths in the first 24 hours of life, early neonatal period (1–6 days), and late neonatal period (7–27 days).

Fig 3. Immediate and antecedent causes of the death when the underlying cause of the death was: Congenital malformation (N1, Fig 3), complication of intrapartum event (N4, Fig 4), infection (N6, Fig 5), respiratory and cardiovascular disorder (N7, Fig 6), and low birth weight and prematurity (N9, Fig 7).

There may be multiple immediate and antecedent causes of death for any individual, so the total number of causes may be greater than is listed in the figure titles.

Fig 4. Immediate and antecedent causes of death when underlying cause was complications of intrapartum event N4 (N = 446).

Immediate and antecedent causes of death.

Fig 5. Immediate and antecedent causes of death when underlying cause was infection N6 (N = 254).

Immediate and antecedent causes of death.

Fig 6. Immediate and antecedent causes of death when underlying cause of death was respiratory and cardiovascular disorders N7 (N = 159).

Immediate and antecedent causes of death.

Fig 7. Immediate and antecedent causes of death when underlying cause was low birth weight and prematurity complications N9 (N = 404).

Immediate and antecedent causes of death.

Fig 8. Pathogens identified in neonatal deaths in which infection was determined in the causal pathway, by age at death.

Fig 9. Expert (DeCoDe) panel determination of whether neonatal deaths were preventable (Fig 9) and recommended improvements that could prevent such deaths (Fig 10).

Fig 10. Recommendations for preventing deaths.