Nigeria’s under-five mortality rate is the eighth highest in the world. Identifying the causes of under-five deaths is crucial to achieving Sustainable Development Goal 3 by 2030 and improving child survival. National and international bodies collaborated in this study to provide the first ever direct estimates of the causes of under-five mortality in Nigeria. Verbal autopsy interviews were conducted of a representative sample of 986 neonatal and 2,268 1–59 month old deaths from 2008 to 2013 identified by the 2013 Nigeria Demographic and Health Survey. Cause of death was assigned by physician coding and computerized expert algorithms arranged in a hierarchy. National and regional estimates of age distributions, mortality rates and cause proportions, and zonal- and age-specific mortality fractions and rates for leading causes of death were evaluated. More under-fives and 1–59 month olds in the South, respectively, died as neonates (N = 24.1%, S = 32.5%, p<0.001) and at younger ages (p<0.001) than in the North. The leading causes of neonatal and 1–59 month mortality, respectively, were sepsis, birth injury/asphyxia and neonatal pneumonia, and malaria, diarrhea and pneumonia. The preterm delivery (N = 1.2%, S = 3.7%, p = 0.042), pneumonia (N = 15.0%, S = 21.6%, p = 0.004) and malaria (N = 34.7%, S = 42.2%, p = 0.009) fractions were higher in the South, with pneumonia and malaria focused in the South East and South South; while the diarrhea fraction was elevated in the North (N = 24.8%, S = 13.2%, p<0.001). However, the diarrhea, pneumonia and malaria mortality rates were all higher in the North, respectively, by 222.9% (Z = -10.9, p = 0.000), 27.6% (Z = -2.3, p = 0.020) and 50.6% (Z = -5.7, p = 0.000), with the greatest excesses in older children. The findings support that there is an epidemiological transition ongoing in southern Nigeria, suggest the way forward to a similar transition in the North, and can help guide maternal, neonatal and child health programming and their regional and zonal foci within the country.

BackgroundRecent studies have shown higher neonatal mortality among births delivered by a skilled attendant at birth (SAB) compared to those who were not in sub–Saharan African countries. Deaths during the neonatal period are concentrated in the first 7 days of life, with about one third of these deaths occurring during the first day of life. We reassessed the relationship between SAB and neonatal mortality by distinguishing deaths on the first day of life from those on days 2–27.MethodsWe used data on births in the past five years from recent demographic and health survey (DHS) between 2010 and 2014 in 20 countries in sub–Saharan Africa. The main categorical outcome was 1) newborns who died within the first day of birth (day 0–1), 2) newborns who died between days 2–27, and 3) newborns who survived the neonatal period. We ran generalized linear mixed model with multinomial distribution and random effect for country on pooled data. Additionally, we ran a separate model restricted to births with SAB and assessed the association of receipt of seven antenatal care (ANC) and two immediate postnatal care interventions on risk of death on days 0–1 and days 2–27. These variables were assessed as proxy of quality of antenatal and postnatal care.ResultsWe found no statistically significant difference in risk of death on first day of life between newborns with SAB compared to those without. However, after the first day of life, newborns delivered with SAB were 16% less likely to die within 2–27 days than those without SAB (OR = 0.84, 95% CI = 0.71–0.99). Among births with skilled attendant, those who were weighed at birth and those who were initiated early on breastfeeding were significantly less likely to die on days 0–1 (respectively OR = 0.42 95% CI = 0.29–0.62 and OR = 0.24, 95% CI 0.18–0.31) or on days 2–27 (OR = 0.60, 95% CI = 0.45–0.81 and OR = 0.59, 95% CI = 47–0.74, respectively). Newborns whose mothers received an additional ANC intervention had no improved survival chances during days 0–1 of life. However, there was significant association on days 2–27 where newborns whose mothers received an additional ANC interventions had higher survival chances (OR = 0.95, 95% CI = 0.93–0.98).ConclusionFindings demonstrate the vulnerability of newborns immediately after birth, compounded with insufficient quality of care. Improving the quality of care around the time of birth will significantly improve survival and therefore accelerate reduction in neonatal mortality in sub–Saharan African countries. Improved approaches for measuring skilled attendant at birth are also needed.

BackgroundMillions 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.MethodsThe 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.ResultsA 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.ConclusionsMaternal, 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.

Background: The majority of documented social accountability initiatives to date have been 'tactical' in nature, employing single-tool, mostly community-based approaches. This article provides lessons from a 'strategic', multitool, multi-level social accountability project: UNICEF's 'Social Accountability for Every Woman Every Child' intervention in Malawi. Methods: The project targeted the national, district and community levels. Three Civil Society Organisations (CSOs) were engaged to carry out interventions using various tools to generate evidence and political advocacy at one or more levels. This article focuses on one of the social accountability methodsthe bwalo forum (a meeting based on a traditional Malawian method of dialogue). A detailed political economy analysis was conducted by one of the co-authors using qualitative methods including interviews and group discussions. The authors conducted incountry consultations and analysed secondary data provided by the CSOs. Results: The political economy analysis highlighted several ways in which CSO partners should modify their work plans to be more compatible with the project context. This included shifting the advocacy and support focus, as well as significantly expanding the bwalo forums. Bwalos were found to be an important platform for allowing citizens to engage with duty bearers at the community and district levels, and enabled a number of reproductive, maternal, newborn, child and adolescent health issues to be resolved at those levels. The project also enabled learning around participant responses as intermediate project outcomes.

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