Care-seeking patterns among families that experienced under-five child mortality in rural Rwanda

Morbidity and unplanned healthcare encounters after hospital discharge among young children in Dar es Salaam, Tanzania and Monrovia, Liberia

BACKGROUND

Researchers and healthcare providers have paid little attention to morbidity and unplanned healthcare encounters for children following hospital discharge in low- and middle-income countries. Our objective was to compare symptoms and unplanned healthcare encounters among children aged <5 years who survived with those who died within 60 days of hospital discharge through follow-up phone calls.

METHODS

We conducted a secondary analysis of a prospective observational cohort of children aged <5 years discharged from neonatal and paediatric wards of two national referral hospitals in Dar es Salaam, Tanzania and Monrovia, Liberia. Caregivers of enrolled participants received phone calls 7, 14, 30, 45, and 60 days after hospital discharge to record symptoms, unplanned healthcare encounters, and vital status. We used logistic regression to determine the association between reported symptoms and unplanned healthcare encounters with 60-day post-discharge mortality.

RESULTS

A total of 4243 participants were enrolled and had 60-day vital status available; 138 (3.3%) died. For every additional symptom ever reported following discharge, there was a 35% greater likelihood of post-discharge mortality (adjusted odds ratio [aOR] 1.35, 95% confidence interval [CI] 1.10 to 1.66; p=0.004). The greatest survival difference was noted for children who had difficulty breathing (2.1% among those who survived vs 36.0% among those who died, p<0.001). Caregivers who took their child home from the hospital against medical advice during the initial hospitalisation had over eight times greater odds of post-discharge mortality (aOR 8.06, 95% CI 3.87 to 16.3; p<0.001) and those who were readmitted to a hospital had 3.42 greater odds (95% CI 1.55 to 8.47; p=0.004) of post-discharge mortality than those who did not seek care when adjusting for site, sociodemographic factors, and clinical variables.

CONCLUSION

Surveillance for symptoms and repeated admissions following hospital discharge by healthcare providers is crucial to identify children at risk for post-discharge mortality.

Identifying delays in healthcare seeking and provision: The Three Delays-in-Healthcare and mortality among infants and children aged 1-59 months

Delays in illness recognition, healthcare seeking, and in the provision of appropriate clinical care are common in resource-limited settings. Our objective was to determine the frequency of delays in the "Three Delays-in-Healthcare", and factors associated with delays, among deceased infants and children in seven countries with high childhood mortality. We conducted a retrospective, descriptive study using data from verbal autopsies and medical records for infants and children aged 1-59 months who died between December 2016 and February 2022 in six sites in sub-Saharan Africa and one in South Asia (Bangladesh) and were enrolled in Child Health and Mortality Prevention Surveillance (CHAMPS). Delays in 1) illness recognition in the home/decision to seek care, 2) transportation to healthcare facilities, and 3) the receipt of clinical care in healthcare facilities were categorized according to the "Three Delays-in-Healthcare". Comparisons in factors associated with delays were made using Chi-square testing. Information was available for 1,326 deaths among infants and under 5 children. The majority had at least one identified delay (n = 854, 64%). Waiting >72 hours after illness recognition to seek health care (n = 422, 32%) was the most common delay. Challenges in obtaining transportation occurred infrequently when seeking care (n = 51, 4%). In healthcare facilities, prescribed medications were sometimes unavailable (n = 102, 8%). Deceased children aged 12-59 months experienced more delay than infants aged 1-11 months (68% vs. 61%, P = 0.018). Delays in seeking clinical care were common among deceased infants and children. Additional study to assess the frequency of delays in seeking clinical care and its provision among children who survive is warranted.

Validation of CHERG'S Verbal Autopsy-Social Autopsy (VASA) tool for ascertaining determinants and causes of under-five child mortality in Pakistan

The majority (40%) of the world's under-five mortality burden is concentrated in nations like Nigeria (16.5%), India (16%), Pakistan (8%), and the Democratic Republic of the Congo (6%), where an undetermined number of under-five deaths go unrecorded. In low-resource settings throughout the world, the Verbal Autopsy-Social Autopsy (VASA) technique may assist assess under-five mortality estimates, assigning medical and social causes of death, and identifying relevant determinants. Uncertainty regarding missing data in high-burden nations like Pakistan necessitates a valid and reliable VASA instrument. This is the first study to validate Child Health Epidemiology Reference Group-CHERG's VASA tool globally. In Pakistan, data from such a valid and reliable tool is vital for policy. This paper reports on the VASA tool in Karachi, Pakistan. Validity and reliability of the CHERG VASA tool were tested using face, content, discriminant validation, and reliability tests on one hundred randomly selected mothers who had recently experienced an under-five child death event. Data were computed on SPSS (version-21) and R software. Testing revealed high Item-content Validity Index (I-CVI) (>81.43%); high Cronbach's Alpha (0.843); the accuracy of between 75-100% of the discriminants classifying births to live and stillbirths; and I-CVI (>82.07% and 88.98% respectively) with high accuracy (92% and 97% respectively) for assigning biological and social causes of child deaths, respectively. The CHERG VASA questionnaire was found relevant to the conceptual framework and valid in Pakistan. This valid tool can assign accurate medical and non-medical causes of child mortality cases occurring in Pakistan.

Factors associated with recovery from stunting at 24 months of age among infants and young children enrolled in the Pediatric Development Clinic (PDC): A retrospective cohort study in rural Rwanda

INTRODUCTION

Stunting (low height/length-for-age) in early life is associated with poor long-term health and developmental outcomes. Nutrition interventions provided during the first 1,000 days of life can result in improved catch-up growth and development outcomes. We assessed factors associated with stunting recovery at 24 months of age among infants and young Children enrolled in Pediatric Development Clinics (PDC) who were stunted at 11 months of age.

METHODS

This retrospective cohort study included infants and young children who enrolled in PDCs in two rural districts in Rwanda between April 2014 and December 2018. Children were included in the study if their PDC enrollment happened within 2 months after birth, were stunted at 11 months of age (considered as baseline) and had a stunting status measured and analyzed at 24 months of age. We defined moderate stunting as length-for-age z-score (LAZ) < -2 and ≥-3 and severe stunting as LAZ <-3 based on the 2006 WHO child growth standards. Stunting recovery at 24 months of age was defined as the child's LAZ changing from <-2 to > -2. We used logistic regression analysis to investigate factors associated with stunting recovery. The factors analyzed included child and mother's socio-demographic and clinical characteristics.

RESULTS

Of the 179 children who were eligible for this study, 100 (55.9%) were severely stunted at age 11 months. At 24 months of age, 37 (20.7%) children recovered from stunting, while 21 (21.0%) severely stunted children improved to moderate stunting and 20 (25.3%) moderately-stunted children worsened to severe stunting. Early stunting at 6 months of age was associated with lower odds of stunting recovery, with the odds of stunting recovery being reduced by 80% (aOR: 0.2; 95%CI: 0.07-0.81) for severely stunted children and by 60% (aOR: 0.4; 95% CI: 0.16-0.97) for moderately stunted children (p = 0.035). Lower odds of stunting recovery were also observed among children who were severely stunted at 11 months of age (aOR: 0.3; 95% CI: 0.1-0.6, p = 0.004). No other maternal or child factors were statistically significantly associated with recovery from stunting at 24 months in our final adjusted model.

CONCLUSION

A substantial proportion of children who were enrolled in PDC within 2 months after birth and were stunted at 11 months of age recovered from stunting at 24 months of age. Children who were severely stunted at 11 months of age (baseline) and those who were stunted at 6 months of age were less likely to recover from stunting at 24 months of age compared to those with moderate stunting at 11 months and no stunting at 6 months of age, respectively. More focus on prevention and early identification of stunting during pregnancy and early life is important to the healthy growth of a child.

Health itinerary-related survival of children under-five with severe malaria or bloodstream infection, DR Congo

BACKGROUND

Prompt appropriate treatment reduces mortality of severe febrile illness in sub-Saharan Africa. We studied the health itinerary of children under-five admitted to the hospital with severe febrile illness in a setting endemic for Plasmodium falciparum (Pf) malaria and invasive non-typhoidal Salmonella infections, identified delaying factors and assessed their associations with in-hospital death.

METHODOLOGY

Health itinerary data of this cohort study were collected during 6 months by interviewing caretakers of children (>28 days - <5 years) admitted with suspected bloodstream infection to Kisantu district hospital, DR Congo. The cohort was followed until discharge to assess in-hospital death.

PRINCIPAL FINDINGS

From 784 enrolled children, 36.1% were admitted >3 days after fever onset. This long health itinerary was more frequent in children with bacterial bloodstream infection (52.9% (63/119)) than in children with severe Pf malaria (31.0% (97/313)). Long health itinerary was associated with in-hospital death (OR = 2.1, p = 0.007) and two thirds of deaths occurred during the first 3 days of admission. Case fatality was higher in bloodstream infection (22.8% (26/114)) compared to severe Pf malaria (2.6%, 8/309). Bloodstream infections were mainly (74.8% (89/119)) caused by non-typhoidal Salmonella. Bloodstream infections occurred in 20/43 children who died in-hospital before possible enrolment and non-typhoidal Salmonella caused 16 out of these 20 bloodstream infections. Delaying factors associated with in-hospital death were consulting traditional, private and/or multiple providers, rural residence, prehospital intravenous therapy, and prehospital overnight stays. Use of antibiotics reserved for hospital use, intravenous therapy and prehospital overnight stays were most frequent in the private sector.

CONCLUSIONS

Long health itineraries delayed appropriate treatment of bloodstream infections in children under-five and were associated with increased in-hospital mortality. Non-typhoidal Salmonella were the main cause of bloodstream infection and had high case fatality.

TRIAL REGISTRATION

NCT04289688.

Healthcare-seeking behavior for children aged 0-59 months: Evidence from 2002-2017 Indonesia Demographic and Health Surveys

BACKGROUND AND OBJECTIVE

Healthcare-seeking behavior for children is crucial for reducing disease severity. Such behavior can improve child health outcomes and prevent child morbidity and mortality. The present study sought to analyze the determinants of mothers' engagement in healthcare-seeking behavior for children with common childhood diseases, focusing on mothers of children aged 0-59 months in Indonesia.

METHODS

This cross-sectional study comprised a secondary data analysis using the 2002-2017 Indonesia Demographic and Health Survey (IDHS) databases. We included all women surveyed aged 15-49 years old who had children under five years of age. We weighted the univariate, bivariate, and multivariate logistic regression analysis of healthcare-seeking behavior for children aged 0-59 months.

RESULTS

We analyzed data for 24,529 women whose children were under five years of age at the time of survey. Common diseases, such as diarrhea, fever, and acute respiratory infection (ARI) were the most frequently cited reasons for healthcare-seeking behavior. During 2002-2017, the proportion of mothers seeking healthcare for their children with diarrhea increased from 67.70% to 69.88%, that with fever increased from 61.48% to 71.64% and that ARI increased from 64.01% to 76.75%. Multivariate analysis revealed that child's age, child's birth order, mother's education, ability to meet expenses, distance to nearest healthcare facility, wealth index, place of residence, and region of residence, were significantly associated with healthcare-seeking behavior.

CONCLUSION

Various individual and environmental-level factors influence healthcare-seeking behavior for childhood diseases. Available, accessible, and affordable health service facilities are recommended to assist socio-economically and geographically disadvantaged families.

Predictors for achieving adequate antenatal care visits during pregnancy: a cross-sectional study in rural Northwest Rwanda

BACKGROUND

Inadequate antenatal care (ANC) in low-income countries has been identified as a risk factor for poor pregnancy outcome. While many countries, including Rwanda, have near universal ANC coverage, a significant proportion of pregnant women do not achieve the recommended regimen of four ANC visits. The present study aimed to explore the factors associated with achieving the recommendation, with an emphasis on the distance from household to health facilities.

METHODS

A geo-referenced cross-sectional study was conducted in Rutsiro district, Western province of Rwanda with 360 randomly selected women. Multiple logistic regression analysis including adjusted odd ratio (aOR) were performed to identify factors associated with achieving the recommended four ANC visits.

RESULTS

The majority (65.3%) of women had less than four ANC visits during pregnancy. We found a significant and negative association between distance from household to health facility and achieving the recommended four ANC visits. As the distance increased by 1 km, the odds of achieving the four ANC visits decreased by 19% (aOR = 0.81, P = 0.024). The odds of achieving the recommended four ANC visits were nearly two times higher among mothers with secondary education compared with mothers with primary education or less (aOR = 1.90, P = 0.038). In addition, mothers who responded that their household members always seek health care when necessary had 1.7 times higher odds of achieving four ANC visits compared with those who responded as unable to seek health care (aOR = 1.7, P = 0.041). Furthermore, mothers from poor households had 2.1 times lower odds of achieving four ANC visits than mothers from slightly better-off households (aOR = 2.1, P = 0.028).

CONCLUSIONS

Findings from the present study suggest that, in Rutsiro district, travel distance to health facility, coupled with socio-economic constraints, including low education and poverty can make it difficult for pregnant women to achieve the recommended ANC regimen. Innovative strategies are needed to decrease distance by bringing ANC services closer to pregnant women and to enhance ANC seeking behaviour. Interventions should also focus on supporting women to attain at least secondary education level as well as to improve the household socioeconomic status of pregnant women, with a particular focus on women from poor households.

Factors Affecting Family Management Among Chinese Parents of Children With Leukemia: A Multisite Study

BACKGROUND

Effective family management can improve the ability of children's families to cope with the disease. However, the family management styles of children with leukemia are unknown.

OBJECTIVE

This study used a family management style framework and structural equation model to determine the direct and indirect predictors of family management of children with leukemia.

METHODS

A total of 496 parents of children with leukemia completed the Family Management Measure, the Feetham Family Functioning Survey, the Social Support Rating Scale, and a demographic family information form. We used structural equation modeling to explore the direct and indirect effects of the study variables on family management styles.

RESULTS

Family functioning, family income, parental education level, and geographic location affect family management directly, among which family functioning has the most significant coefficient in the model (0.53). Siblings and social support can affect family management through the mediating effect of family functioning. Employment change can directly affect family management (-0.27) and indirectly affect family functioning (-0.08).

CONCLUSIONS

Our results support the family management style framework. Individual and family factors such as family income, parental education level, geographic location, employment change, siblings, and social support contribute to the ease or difficulty of family management. In addition, family functioning can also mediate between contextual influences and family management styles.

IMPLICATIONS FOR PRACTICE

Family functioning plays a vital role in relationships between contextual influences and family management. We can construct family management interventions according to family management influencing factors.

A Prospective, observational cohort study to identify neonates and children at risk of postdischarge mortality in Dar es Salaam, Tanzania and Monrovia, Liberia: the PPDM study protocol

INTRODUCTION

Over half of the 5 million annual deaths among children aged 0-59 months occur in sub-Saharan Africa. The period immediately after hospitalisation is a vulnerable time in the life of a child in sub-Saharan Africa as postdischarge mortality rates are as high as 1%-18%. Identification of neonates and children who are at highest risk for postdischarge mortality may allow for the direction of interventions to target patients at highest risk.

METHODS AND ANALYSIS

The Predicting Post-Discharge Mortality study is a prospective, observational study being conducted at Muhimbili National Hospital (Dar es Salaam, Tanzania) and John F. Kennedy Medical Center (Monrovia, Liberia). The aim is to derive and validate two, age population specific, clinical prediction rules for the identification of neonates (n=2000) and children aged 1-59 months (n=2000) at risk for all-cause mortality within 60 days of discharge from the neonatal intensive care unit or paediatric ward. Caregivers of participants will receive phone calls 7, 14, 30, 45 and 60 days after discharge to assess vital status. Candidate predictor variables will include demographic, anthropometric and clinical factors. Elastic net regression will be used to derive the clinical prediction rules. Bootstrapped selection with repetitions will be used for internal validation. Planned secondary analyses include the external validation of existing clinical prediction models, determination of clinicians' ability to identify neonates and children at risk of postdischarge mortality at discharge, analysis of factors associated with hospital readmission and unplanned clinic visits and description of health-seeking behaviours in the postdischarge period.

ETHICS AND DISSEMINATION

This study received ethical clearance from the Tanzania National Institute of Medical Research, Muhimbili University of Health and Allied Sciences, the John F. Kennedy Medical Center Institutional Review Board, and the Boston Children's Hospital Institutional Review Board. Findings will be disseminated at scientific conferences and as peer-reviewed publications.

Health care seeking behaviour for children with acute childhood illnesses and its relating factors in sub-Saharan Africa: evidence from 24 countries

BACKGROUND

Childhood illnesses and mortality rates have declined over the past years in sub-Saharan African countries; however, under-five mortality is still high in the region. This study investigated the magnitude and factors associated with health care seeking behaviour for children with childhood illnesses in 24 sub-Saharan African countries.

METHODS

We used secondary data from Demographic and Health Surveys (DHSs) conducted between 2013 and 2018 across the 24 sub-Saharan African countries. Binary logistic regression models were applied to identify the factors associated with health care seeking behaviour for children with acute childhood illnesses. The results were presented using adjusted odds ratios (aOR) with 95% confidence intervals (CIs).

RESULTS

Overall, 45% of children under-5 years with acute childhood illnesses utilized health care facilities. The factors associated with health care seeking behaviour for children with acute illnesses were sex of child, number of living children, education, work status, wealth index, exposure to media and distance to a health facility.

CONCLUSIONS

Over half of mothers did not seek appropriate health care for under-five childhood illnesses. Effective health policy interventions are needed to enhance health care seeking behaviour of mothers for childhood illnesses in sub-Saharan African countries.

Community-based amoxicillin treatment for fast breathing pneumonia in young infants 7-59 days old: a cluster randomised trial in rural Bangladesh, Ethiopia, India and Malawi

INTRODUCTION

Young infants 7-59 days old with fast breathing pneumonia presented to a primary level health facility receive a 7-day course of amoxicillin as per the WHO guideline. However, community-level health workers (CLHW) are not allowed to treat these infants. This trial evaluated the community level treatment of non-hypoxaemic young infants with fast breathing pneumonia by CLHWs.

METHODS

This cluster-randomised, open-label, non-inferiority trial was conducted in rural areas of Bangladesh, Ethiopia, India and Malawi. We randomly allocated clusters (first-level health facility) 1:1, stratified by the population size, to an intervention group (enhanced community case management) or control group (standard community case management). Infants aged 7-59 days with a respiratory rate of ≥60 breaths/min and oxygen saturation (SpO2) ≥90% were enrolled. In the intervention clusters, these infants were treated with a 7-day course of oral amoxicillin (according to WHO weight bands) and were regularly followed up by CLHWs. In the control clusters, CLHWs continued the standard management (assess and refer after pre-referral antibiotic dose) and followed up according to the national programme guideline. The primary outcome of treatment failure was assessed in both groups by independent outcome assessors on days 6 and 14 after enrolment. Secondary outcomes (accuracy and impact of pulse oximetry) were also assessed.

RESULTS

Between September 2016 and December 2018, we enrolled 2334 infants (1168 in intervention and 1166 in control clusters) from 208 clusters (104 intervention and 104 control). Of 2334, 22 infants with fast breathing were excluded from analysis, leaving 2312 (1155 in intervention clusters and 1157 in control clusters) for intention-to-treat analysis. The proportion of treatment failure was 5.4% (63/1155) in intervention and 6.3% (73/1157) in the control clusters, including two deaths (0.2%) in each group. The adjusted risk difference for treatment failure between the two groups was -1.0% (95% CI -3.0% to 1.1%). The secondary outcome showed that CLHWs in the intervention clusters performed all recommended steps of pulse oximetry assessment in 94% (1050/1115) of enrolled patients.

CONCLUSIONS

The 7-day amoxicillin treatment for 7-59 days old non-hypoxaemic infants with fast breathing pneumonia by CLHWs was non-inferior to the currently recommended referral strategy.

TRIAL REGISTRATION NUMBERS

CTRI/2017/02/007761 and ACTRN12617000857303.

Factors associated with delays in the search for care in under-5 deaths in Yucatán, Mexico

OBJECTIVE

We examined delays during the search for care and associations with mother, child, or health services characteristics, and with symptoms reported prior to death.

MATERIALS AND METHODS

Cross-sectional study compris-ing household interviews with 252 caregivers of children under-5 who died in the state of Yucatán, Mexico, during 2015-2016. We evaluated the three main delays: 1) time to identify symptoms and start search for care, 2) transport time to health facility, and 3) wait time at health facility.

RESULTS

Children faced important delays including a mean time to start the search for care of 4.1 days. The mean transport time to the first facility was longer for children enrolled in Seguro Popular and there were longer wait times at public facilities, especially among children who also experienced longer travel time.

CONCLUSIONS

Providing resources to enable caregiv-ers to access health services in a timely manner may reduce delays in seeking care.

Distance to primary care facilities and healthcare utilization for preschool children in rural northwestern Burkina Faso: results from a surveillance cohort

Background

Delays in care-seeking for childhood illness may lead to more severe outcomes. We evaluated whether community distance from a primary healthcare facility was associated with decreased healthcare utilization in a rural district of northwestern Burkina Faso.

Methods

We conducted passive surveillance of all government-run primary healthcare facilities in Nouna District, Burkina Faso from March 1 through May 31, 2020. All healthcare visits for children under 5 years of age were recorded on a standardized form for sick children. We recorded the age, sex, and community of residence of the child as well as any diagnoses and treatments administered. We calculated healthcare utilization per 100 child-months by linking the aggregate number of visits at the community level to the community’s population of children under 5 months per a census that was conducted from August 2019 through February 2020. We calculated the distance between each community and its corresponding healthcare facility and assessed the relationship between distance and the rate of healthcare utilization.

Results

In 226 study communities, 12,676 primary healthcare visits were recorded over the three-month period. The median distance between the community and primary healthcare facility was 5.0 km (IQR 2.6 to 6.9 km), and median number of healthcare visits per 100 child-months at the community level was 6.7 (IQR 3.7 to 12.3). The rate of primary healthcare visits declined with increasing distance from clinic (Spearman’s rho − 0.42, 95% CI − 0.54 to − 0.31, P < 0.0001). This relationship was similar for cause-specific clinic visits (including pneumonia, malaria, and diarrhea) and for antibiotic prescriptions.

Conclusions

We documented a distance decay effect between community distance from a primary healthcare facility and the rate of healthcare visits for children under 5. Decreasing distance-related barriers, for example by increasing the number of facilities or targeting outreach to more distant communities, may improve healthcare utilization for young children in similar settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06226-5.

Risk factors for mortality among Tanzanian infants and children

BACKGROUND

During the era of the Millennium Development Goals, under 5 mortality rates decreased significantly worldwide; however, reductions were not equally distributed. Children in sub-Saharan Africa still account for more than 50% of the world's annual childhood deaths among children under 5 years of age. Understanding upstream risk factors for mortality among children may reduce the large burden of childhood mortality in sub-Saharan Africa. Our objective was to identify risk factors for mortality among infants and children in Tanzania.

METHODS

We conducted a secondary analysis of data pooled from two randomized-controlled micronutrient supplementation trials. A total of 4787 infants were enrolled in the two trials (n = 2387 HIV-exposed and n = 2400 HIV-unexposed). Predictors of mortality were assessed using unadjusted and adjusted hazard ratios (aHRs).

RESULTS

There were 307 total deaths, 262 (11%) among children who were HIV-exposed and 45 (2%) among children who were HIV-unexposed (P < 0.001). The most common cause of death was respiratory diseases (n = 109, 35.5%). Causes of death did not significantly differ between HIV-exposed and HIV-unexposed children. In adjusted regression analyses, children with birth weight <2500 g (aHR 1.75, 95% CI 1.21-2.54), Apgar score of ≤7 at 5 min (aHR 2.16, 95% CI 1.29-3.62), or who were HIV-exposed but not infected (aHR 3.35, 95% CI 2.12-5.28) or HIV-infected (aHR 27.56, 95% CI 17.43-43.58) had greater risk of mortality.

CONCLUSIONS

Infection with HIV, low birthweight, or low Apgar scores were associated with higher mortality risk. Early identification and modification of determinants of mortality among infants and children may be the first step to reducing such deaths.

Place of death, care-seeking and care pathway progression in the final illnesses of children under five years of age in sub-Saharan Africa: a systematic review

Background

Half of all under-5 deaths occur in sub-Saharan Africa. Reducing child mortality requires understanding of the modifiable factors that contribute to death. Social autopsies collect information about place of death, care-seeking and care-provision, but this has not been pooled to learn wider lessons. We therefore undertook a systematic review to collect, evaluate, map, and pool all the available evidence for sub-Saharan Africa.

Methods

We searched PubMed, Embase, Global Health, the Cochrane Library and grey literature for studies relating to under-5 deaths in sub-Saharan Africa with information on place of death and/or care-seeking during a child’s final illness. We assessed study quality with a modified Axis tool. We pooled proportions using random effects meta-analysis for place of death and for each stage of the Pathways to Survival framework. Pre-specified subgroup analysis included age group, national income and user-fee policy. We explored heterogeneity with meta-regression. Our protocol was published prospectively (CRD42018111484).

Results

We included 34 studies from 17 countries. Approximately half of the children died at home, irrespective of age. More children died at home in settings with user-fees (69.1%, 95% confidence interval (CI) = 56.2-80.6, I² = 98.4%) compared to settings without user-fees (43.8%, 95% CI = 34.3-53.5, I² = 96.7%). Signs of illness were present in over 95% of children but care-seeking differed by age. 40.1% of neonates (95% CI = 20.7-61.3, I² = 98.0%) died without receiving any care, compared to 6.4% of older children (95% CI = 4.2%-9.0%, I² = 90.6%). Care-seeking outside the home was less common in neonatal deaths (50.5%, 95% CI = 35.6-65.3, I² = 98.3%) compared to infants and young children (82.4%, 95% CI = 79.4%-85.2%, I² = 87.5%). In both age groups, most children were taken for formal care. Healthcare facilities discharged 69.6% of infants and young children who arrived alive (95% CI = 59.6-78.7, I² = 95.5%), of whom only 34.9% were referred for further care (95% CI = 15.1-57.9, I² = 98.7%).

Conclusions

Despite similar distributions in place of death for neonates and infants and young children, care-seeking behaviour differed by age groups. Poor illness recognition is implicated in neonatal deaths, but death despite care-seeking implies inadequate quality care and referral for older children. Understanding such care-seeking patterns enables targeted interventions to reduce under-5 mortality across the region.

Estimating hospital catchments from in-patient admission records: a spatial statistical approach applied to malaria

Admission records are seldom used in sub-Saharan Africa to delineate hospital catchments for the spatial description of hospitalised disease events. We set out to investigate spatial hospital accessibility for severe malarial anaemia (SMA) and cerebral malaria (CM). Malaria admissions for children between 1 month and 14 years old were identified from prospective clinical surveillance data recorded routinely at four referral hospitals covering two complete years between December 2015 to November 2016 and November 2017 to October 2018. These were linked to census enumeration areas (EAs) with an age-structured population. A novel mathematical-statistical framework that included EAs with zero observations was used to predict hospital catchment for malaria admissions adjusting for spatial distance. From 5766 malaria admissions, 5486 (95.14%) were linked to specific EA address, of which 272 (5%) were classified as cerebral malaria while 1001 (10%) were severe malaria anaemia. Further, results suggest a marked geographic catchment of malaria admission around the four sentinel hospitals although the extent varied. The relative rate-ratio of hospitalisation was highest at <1-hour travel time for SMA and CM although this was lower outside the predicted hospital catchments. Delineation of catchments is important for planning emergency care delivery and in the use of hospital data to define epidemiological disease burdens. Further hospital and community-based studies on treatment-seeking pathways to hospitals for severe disease would improve our understanding of catchments.

Projected impact and cost-effectiveness of community-based versus targeted azithromycin administration strategies for reducing child mortality in sub-Saharan Africa

BACKGROUND

Trials of mass drug administration (MDA) of azithromycin (AZM) report reductions in child mortality in sub-Saharan Africa (SSA). AZM targeted to high-risk children may preserve benefit while minimizing antibiotic exposure. We modeled the cost-effectiveness of MDA to children 1-59 months of age, MDA to children 1-5 months of age, AZM administered at hospital discharge, and the combination of MDA and post-discharge AZM.

METHODS AND FINDINGS

Models employed a payer perspective with a 1-year time horizon. Cost-effectiveness was presented as cost per DALY averted and death averted, with probabilistic sensitivity analyses. The model included parameters for macrolide resistance, adverse events, hospitalization, and mortality sourced from published data. Assuming a base-case 1.64% mortality risk among children 1-59 months old, 3.1% among children 1-5 months old, 4.4% mortality risk post-discharge, and 13.5% mortality reduction per trial data, post-discharge AZM would avert ~45,000 deaths, at a cost of $2.84/DALY (95% uncertainty interval [UI]: 1.71-5.57) averted. MDA to only children 1-5 months old would avert ~186,000 deaths at a cost of $4.89/DALY averted (95% UI: 2.88-11.42), MDA to all under-5 children would avert ~267,000 deaths a cost of $14.26/DALY averted (95% UI: 8.72-27.08). Cost-effectiveness decreased with presumed diminished efficacy due to macrolide resistance.

CONCLUSIONS

Targeting AZM to children at highest risk of death may be an antibiotic-sparing and cost-effective, or even cost-saving, strategy to reduce child mortality. However, targeted AZM averts fewer absolute deaths and may not reach all children who would benefit. Any AZM administration decision must consider implications for antibiotic resistance.

Mortality Associated With Acute Respiratory Infections Among Children at Home

Background

Numerous deaths in children aged <5 years in the developing world occur at home. Acute respiratory infections (ARIs) are thought to play an important role in these deaths. Risk factors and pathogens linked to fatal episodes remain unclear.

Methods

A case-control study among low-income children aged <5 years was performed in Buenos Aires, Argentina, to define risk factors and viral pathogens among those who died of ARI at home.

Results

A total of 278 families of children aged <5 years (of whom 104 died and 174 were healthy controls) participated in the study. A total of 87.5% of ARI-associated deaths occurred among infants aged <12 months. The estimated mortality rate due to ARI among infants was 5.02 deaths/1000 live births. Dying at home from ARI was associated with living in a crowded home (odds ratio [OR], 3.73; 95% confidence interval [CI], 1.41-9.88), having an adolescent mother (OR, 4.89; 95% CI, 1.37-17.38), lacking running water in the home (OR, 4.39; 95% CI, 1.11-17.38), incomplete vaccinations for age (OR, 3.39; 95% CI, 1.20-9.62), admission to a neonatal intensive care unit (OR, 7.17; 95% CI, 2.21-23.27), and no emergency department visit during the ARI episode (OR, 72.32; 95% CI, 4.82-1085.6). The at-home death rate due to respiratory syncytial virus infection among infants was 0.26 deaths/100 live births and that due to influenza was 0.07 deaths/1000 live births.

Conclusions

Social vulnerabilities underlie at-home mortality due to ARI. Mortality rates due to RSV and influenza virus infection are high among infants at home and are similar to those reported for hospitalized children.

Care pathways during a child's final illness in rural South Africa: Findings from a social autopsy study

BACKGROUND

Half of under-5 deaths in South Africa occur at home, however the reasons remain poorly described and data on the care pathways during fatal childhood illness is limited. This study aimed to better describe care-seeking behavior in fatal childhood illness and to assess barriers to healthcare and modifiable factors that contribute to under-5 deaths in rural South Africa.

METHODS

We conducted a social autopsy study on all under-5 deaths in two rural South African health and demographic surveillance system sites. Descriptive analyses based on the Pathways to Survival Framework were used to characterise how caregivers move through the stages of seeking and providing care for children during their final illness and to identify modifiable factors that contributed to death.

FINDINGS

Of 53 deaths, 40% occurred outside health facilities. Rates of antenatal and perinatal preventative care-seeking were high: over 70% of mothers had tested for HIV, 93% received professional assistance during delivery and 79% of children were reportedly immunised appropriately for age. Of the 48 deaths tracked through the stages of the Pathways to Survival Framework, 10% died suddenly without any care, 23% received home care of whom 80% had signs of severe or possibly severe illness, and 85% sought or attempted to seek formal care outside the home. Although half of all children left the first facility alive, only 27% were referred for further care.

CONCLUSIONS

Modifiable factors for preventing deaths during a child's final illness occur both inside and outside the home. The most important modifiable factors occurring inside the home relate to caregivers' recognition of illness and appreciation of urgency in response to the severity of the child's symptoms and signs. Outside the home, modifiable factors relate to inadequate referral and follow-up by health professionals. Further research should focus on identifying and overcoming barriers to referral.

All-cause child mortality in minority and non-minority areas in Sichuan Province in Western China, 2008-2017

This study aimed to evaluate the disparity in the under-five mortality rate (U5MR) between minority and non-minority areas in Sichuan Province in Western China. Data for this study was obtained from the National Health Statistics Survey System. The Cochran-Armitage trend test was used to analyze the time trend of the U5MR. We conducted Poisson regression model to compare the differences of U5MRs between minority and non-minority areas. The U5MR in Sichuan province was reduced by 62.19% from 2008 to 2017, with the minority and non-minority areas reduced by 60.48% and 65.39%, respectively. The under-five mortality risk in minority areas was approximately 1.791 times (95% CI: 1.790–1.793; P < 0.01) that in non-minority areas. The primary cause of death of children under-five years old in minority areas was the respiratory disease, which was significantly higher than that in non-minority areas (P all < 0.01). The U5MR significantly declined both in minority and non-minority areas in Sichuan Province in Western China from 2008 to 2017. However, disparities still existed between minority and non-minority areas. Respiratory diseases were the main causes of death in minority areas and corresponding rates were higher than those in non-minority areas.

Very severe anemia and one year mortality outcome after hospitalization in Tanzanian children: A prospective cohort study

BACKGROUND

Africa has the highest rates of child mortality. Little is known about outcomes after hospitalization for children with very severe anemia.

OBJECTIVE

To determine one year mortality and predictors of mortality in Tanzanian children hospitalized with very severe anemia.

METHODS

We conducted a prospective cohort study enrolling children 2-12 years hospitalized from August 2014 to November 2014 at two public hospitals in northwestern Tanzania. Children were screened for anemia and followed until 12 months after discharge. The primary outcome measured was mortality. Predictors of mortality were determined using Cox regression analysis.

RESULTS

Of the 505 children, 90 (17.8%) had very severe anemia and 415 (82.1%) did not. Mortality was higher for children with very severe anemia compared to children without over a one year period from admission, 27/90 (30.0%) vs. 59/415 (14.2%) respectively (Hazard Ratio (HR) 2.42, 95% Cl 1.53-3.83). In-hospital mortality was 11/90 (12.2%) and post-hospital mortality was 16/79 (20.2%) for children with very severe anemia. The strongest predictors of mortality were age (HR 1.01, 95% Cl 1.00-1.03) and decreased urine output (HR 4.30, 95% Cl 1.04-17.7).

CONCLUSIONS

Children up to 12 years of age with very severe anemia have nearly a 30% chance of mortality following admission over a one year period, with over 50% of mortality occurring after discharge. Post-hospital interventions are urgently needed to reduce mortality in children with very severe anemia, and should include older children.

Unintentional injury mortality among children under age five in urban and rural areas in the Sichuan province of west China, 2009-2017

This study analysed trends in the unintentional injuries specific mortality rates among children under age five (UI-specific U5MRs) in urban and rural areas in the Sichuan province of western China. Data were obtained from the National Health Statistics Survey System. The Cochran-Armitage trend test was used to analyse the trends in UI-specific U5MRs and the proportion of unintentional injury deaths to total deaths. The Poisson regression model was used to compare the UI-specific U5MRs between rural and urban areas. The overall UI-specific U5MRs decreased from 3.8 to 1.7 per 1,000 live births from 2009 to 2017, with an average annual decline in the rates of 8.78% and 10.05% in urban and rural areas, respectively. The UI risk of death in rural areas was approximately 1.95 times that in urban areas (95% CI: 1.73-2.18; p < 0.01). A total of 49.9% of all the children in the study did not receive any treatment before death caused by UI. The UI-specific U5MRs significantly declined in Sichuan province from 2009 to 2017, but large disparities in UI-specific U5MRs in urban and rural areas still exist. Reducing the U5MRs due to UI should be a major public health concern in western China.

Care seeking behaviour and aspects of quality of care by caregivers for children under five with and without pneumonia in Ibadan, Nigeria

BACKGROUND

This study aimed to investigate the differences in reported care seeking behaviour and treatment between children with pneumonia and children without pneumonia with cough and/or difficult breathing.

METHODS

Three hundred and two children aged 0-59 months with fast breathing pneumonia were matched with 302 children seeking care for cough and/or difficult breathing at four outpatient clinics in Ibadan, Nigeria. After follow up at home, Demographic and Health Survey (DHS) and Multiple Indicator Cluster Survey (MICS) questionnaires were administered in the community by trained field workers to gather information around care seeking delay, patterns of care seeking, appropriateness of care seeking and treatment provided once care was sought. Multivariable analysis was carried out to determine significant factors associated with care seeking delay.

RESULTS

Children with pneumonia had a significantly longer delay (median = 3d) before seeking care than those without pneumonia (median = 2d; P = 0.001). The length of the delay was 21% (95% confidence interval (CI) = 1%-42%) greater in those aged 0-1 month and 11% (95% CI = 5%-42%) greater in those aged 2-11 months compared to those aged 12-59 months. The length of delay was 17% (95% CI = 5%-30%) greater in rural locations than urban ones, and 33% (95% CI = 7%-51%) shorter in fathers with only primary education compared to higher education, adjusted for covariates. The range of places where care was sought showed the same distribution in those with and without pneumonia. Twenty two per cent of those with pneumonia sought care first from inappropriate providers. The number of children for whom caregivers reported having received antibiotic treatment was 92% for those with pneumonia and 84% for those without pneumonia.

CONCLUSIONS

Given that children with pneumonia and cough/cold had similar patterns of reported care seeking information gathered on care seeking (type of provider visited) from DHS and MICS surveys on those with 'symptoms of acute respiratory infection' in this setting provide a reasonably valid indication of care seeking behaviours in children with pneumonia. There are high levels of antibiotic overuse for children with cough/cold in this setting which risks worsening antibiotic resistance.