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Background: Household surveys undertaken in Niger since 1998 have revealed steady declines in under-5 mortality which have placed the country ‘on track’ to reach the fourth Millennium Development goal (MDG). This paper explores Niger’s mortality and health coverage data for children under-5 years of age up to 2012 to describe trends in high impact interventions and the resulting impact on childhood deaths averted. The sustainability of these trends are also considered. Methods and Findings: Estimates of child mortality using the 2012 Demographic and Health Survey were developed and maternal and child health coverage indicators were calculated over four time periods. Child survival policies and programmes were documented through a review of documents and key informant interviews. The Lives Saved Tool (LiST) was used to estimate the number of child lives saved and identify which interventions had the largest impact on deaths averted. The national mortality rate in children under-5 decreased from 286 child deaths per 1000 live births (95% confidence interval 177 to 394) in the period 1989-1990 to 128 child deaths per 1000 live births in the period 2011-2012 (101 to 155), corresponding to an annual rate of decline of 3.6%, with significant declines taking place after 1998. Improvements in the coverage of maternal and child health interventions between 2006 and 2012 include one and four or more antenatal visits, maternal Fansidar and tetanus toxoid vaccination, measles and DPT3 vaccinations, early and exclusive breastfeeding, oral rehydration salts (ORS) and proportion of children sleeping under an insecticide-treated bed net (ITN). Approximately 26,000 deaths of children under-5 were averted in 2012 due to decreases in stunting rates (27%), increases in ORS (14%), the Hib vaccine (14%), and breastfeeding (11%). Increases in wasting and decreases in vitamin A supplementation negated some of those gains. Care seeking at the community level was responsible for an estimated 7,800 additional deaths averted in 2012. A major policy change occurred in 2006 enabling free health care provision for women and children, and in 2008 the establishment of a community health worker programme. Conclusion: Increases in access and coverage of care for mothers and children have averted a considerable number of childhood deaths. The 2006 free health care policy and health post expansion were paramount in reducing barriers to care. However the sustainability of this policy and health service provision is precarious in light of persistently high fertility rates, unpredictable GDP growth, a high dependence on donor support and increasing pressures on government funding.
The evaluation included all nationally representative household survey datasets available: 2000 Multiple Indicator Cluster Survey (MICS) [21], 2006 DHS [22], 2010 Survival and Mortality Survey [23], and 2012 DHS [24]. The 1998 DHS collected data only for children up to 3 years of age, and was therefore excluded from this analysis for comparability purposes, as many of the indicators that were analysed across survey years included children up to 5 years of age. Estimates of intervention coverage at population level from the 2006 and 2012 DHS were used as inputs to the Lives Saved Tool (LiST) to model the overall estimated lives saved as well as the additional independent impact of care seeking at the community level on deaths averted. Birth and death history data of all children of women aged 15 to 49 years sampled in the 2012 DHS was used to calculate under-5 mortality. Full survey datasets with district sampling weights were used for the analysis. For further details on the surveys included in the analysis see Table A in S1 File. Adjustments were made to align indicator definitions across the DHS, MICS and 2010 Survival and Mortality surveys (S1 File: Additional methods information). Contextual information about child health policies, CI/IHSS implementation and other relevant child health programmes was obtained through a desk review of documents and databases, and key informant interviews conducted during a 10-day country visit (April 2013). The information gathered from these sources was used to compile a policy and programme timeline (Fig 1). For further details on the contextual analysis see Box B in S1 File. For under-5 mortality estimation, we used a direct method based on the synthetic cohort approach [25, 26]. Age-specific mortality probabilities for narrow age ranges and defined periods were calculated using death events and exposures. These probabilities were combined to compute the probability that a child has not died before reaching age 5 years. Two year periods were used beginning with two years before the survey, and survival probabilities were calculated over age ranges; 0, 1–2, 3–5, 6–11, 12–23, 24–35, 36–47, 48–59 months as recommended by DHS (S1 File: Mortality analysis) [26]. The standard errors for the computed mortality estimates were obtained using the Jackknife variance estimation, a repeated sampling method [25]. A series of mortality estimates were obtained by deleting and replacing each primary sampling unit; this produced a sample of under-5 estimates, from which the variance was computed in turn. For more information see see S1 File: Mortality analysis. All relevant coverage indicators from each survey dataset were calculated using standard definitions for tracking progress towards MDG 4 [27]. Anthropometric indicators including stunting and wasting in children under-5 years of age were calculated from raw survey data using the 2006 WHO child growth standards. For stunting and wasting, moderate and severe forms were aggregated. Significant differences in coverage of pertinent indicators between survey years were determined based on the overlap in the 95% confidence intervals around the estimates. Changes in care-seeking patterns were also analysed, with a particular focus on community level care-seeking. Data relating to care sought and received for fever, suspected pneumonia and diarrhoea were extracted from available surveys. The sampling design of these household surveys such as regional and rural/urban stratification, clustering at enumeration areas and sampling weights (due to non-proportional sampling) were taken into account. Stata (version 12) was used for coverage and mortality trend analyses. The retrospective LiST analysis investigated the extent to which changes in mortality could be associated with changes in intervention coverage between 2006 and 2012. Annual coverage values were interpolated linearly between the 2006 and 2012 household survey data points, using only DHS to maintain comparability of sources. In this analysis, anthropometric data were entered directly into the model in order to calculate deaths averted due to decreases in stunting and wasting rates. LiST methods and inputs have been widely published [28–30]. Further details on the LiST analysis can be found in S1 File: Additional details regarding the LiST analysis. To quantify the impact of increased health access through community level services on child mortality, we used LiST to estimate the deaths averted between 2006 and 2012 from all care-seeking for childhood illness at appropriate providers (i.e. not including pharmacies, shops and traditional practitioners), using methods described in detail elsewhere [31]. We compared this with a scenario where care-seeking at community level (i.e. from ASCs and health posts) was removed from the coverage estimates in order to determine the number of lives saved that could be attributed to the introduction of community level services. This study was approved by the ethics committee of the South African Medical Research Council (EC026-9/2012). Approval was also provided by the UNICEF Niger country office. Data for the analysis of intervention coverage and mortality was taken from secondary sources (nationally representative household surveys) which are anonymized and de-identified prior to public release.
