Verbal/social autopsy study helps explain the lack of decrease in neonatal mortality in Niger, 2007–2010

Abstract

BackgroundThis study was one of a set of verbal/social autopsy (VASA) investigations undertaken by the WHO/UNICEF–supported Child Health Epidemiology Reference Group to estimate the causes and determinants of neonatal and child deaths in high priority countries. The study objective was to help explain the lack of decrease in neonatal mortality in Niger from 2007 to 2010, a period during which child mortality was decreasing.MethodsVASA interviews were conducted of a random sample of 453 neonatal deaths identified by the 2010 Niger National Mortality Survey (NNMS). Causes of death were determined by expert algorithm analysis, and the prevalence of household, community and health system determinants were examined along the continuum of maternal and newborn care, the Pathway to Survival for newborn illnesses, and an extended pathway for maternal complications. The social autopsy findings were compared to available data for survivors from the same cohort collected by the NNMS and the 2012 Niger Demographic and Health Survey.FindingsSevere neonatal infection and birth asphyxia were the leading causes of early neonatal death in the community and facilities. Death in the community after delayed careseeking for severe infection predominated during the late neonatal period. The levels of nearly all demographic, antenatal and delivery care factors were in the direction of risk for the VASA study decedents. They more often resided rurally (P < 0.001) and their mothers were less educated (P = 0.03) and gave birth when younger (P = 0.03) than survivors’ mothers. Their mothers also were less likely to receive quality antenatal care (P < 0.001), skilled attendance at birth (P = 0.03) or to deliver in an institution (P < 0.001). Nearly half suffered an obstetric complication, with more maternal infection (17.9% vs 0.2%), antepartum hemorrhage (12.5% vs 0.5%) and eclampsia/preeclampsia (9.5% vs 1.6%) than for all births in Niger. Their mothers also were unlikely to seek health care for their own complications (37% to 42%) as well as for the newborn’s illness (30.6%).ConclusionsNiger should scale up its recently implemented package of high–impact interventions to additional integrated health facilities and expand the package to provide antenatal care and management of labor and delivery, with support to reach a higher level facility when required. Community interventions are needed to improve illness recognition and careseeking for severe neonatal infection.

Using social autopsy to understand maternal, newborn, and child mortality in low-resource settings: a systematic review of the literature

“…For example, in Uganda [11], 96% of respondents recognized severe symptoms in their children under the age of 5 before death, but a third were treated at home before going to a facility. Similarly, in Niger [12], while 95.8% of pregnant women’s caregivers reported a serious or severe symptom prior to death, 60.3% of women received no care for their illness. In Malawi, 97.8% of caretakers recognized a severe or possibly severe symptom, but only 61.1% sought or tried to seek care [14].…”

“…Twelve of the 16 studies provided glimpses into some of the other reasons families may not be seeking prompt attention. These included perceived low quality of care at the facility [6,9,17,21], attributing illness to spiritual and other non-medical causes [6,8,18,19], thinking that the baby would die anyway or was too sick to travel [12,14], thinking that the baby was not sick enough to seek care [14], not having a family member to accompany the woman to the facility [12,20], and needing husband’s permission to seek care [8]. Specific examples of how such barriers influence care include that in Bangladesh, 18% of mothers said they did not bring the baby for care because they thought it would die anyway [18].…”

In-depth Validation of CHERG’S Verbal Autopsy-Social Autopsy (VASA) Tool for Ascertaining Determinants and Causes of Under-Five Child Mortalities in Karachi, Pakistan.

“…Moreover, VASA, an integrated approach, whereby VA is merged with SA to identify not only the medical causes of mortalities but also to identify the social contributors of child deaths. This integrated tool is under trial in some of the low resource settings across the globe (4,(6)(7)(8)(9). Literature suggests that CHERG (Child Health Epidemiology Reference Group) VASA integrated tool, which is based on the so-far most holistic conceptual framework, i.e., "The Pathway to Survival Conceptual Framework" (TPtoSCF) (10), have been utilized in several countries (6,7,9,11) for exploring the most relevant medical and social determinants of mortality events.…”

“…This information ultimately helps the epidemiologists in assigning the medical and social causes to child deaths. The extensive data obtained from VASA tool based investigations provides highly elaborated evidence and information on extended determinants of child mortality which is of great public health importance (4,6,12).…”

Methodologies of Verbal autopsy and Social autopsy tools, adopted by VASA studies in exploring under-five mortality determinants

“…This approach can give extended data on most relevant biological and social determinants related to specific death event and ultimately help in assigning a broader cause of death. However, the literature shows that such investigations have been undertaken by either way; administering VA and SA tools separately (but in synergy) for each death event [28][29][30][31] or using an integrated tool where SA is merged with VA, thereby making a single tool for recording data on biological and social determinants 8, [21][22][23][24][25][26][32][33][34][35] . However, logically, the single integrated tool should be based on an integrated CF that should be holistic in recording biological and social determinants of child mortality.…”