Causes of death and predictors of childhood mortality in Rwanda: A matched case-control study using verbal social autopsy

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Study Justification:
– Rwanda has made significant progress in reducing child mortality, but there is a need to understand the causes and sociodemographic factors contributing to childhood deaths.
– The study aims to identify the causes of death and risk factors for childhood mortality in Rwanda, particularly in the eastern province.
– By understanding the specific causes and risk factors, interventions can be targeted to reduce childhood mortality further.
Study Highlights:
– The study identified 618 deaths in children under 5 years of age, with 28.2% in neonates and 71.8% in non-neonates.
– The most common causes of death in neonates were pneumonia, birth asphyxia, and meningitis, while malaria, acute respiratory infections, and HIV/AIDS-related deaths were common in non-neonates.
– Home deliveries were found to be a significant risk factor for neonatal death.
– Other risk factors for neonatal death included multiple gestation, both parents deceased, mothers non-use of family planning, lack of accompanying person, and caregiver dissatisfaction with medical services.
– Risk factors for non-neonatal deaths included multiple gestation, lack of adequate vaccinations, household size, maternal education levels, mothers non-use of family planning, and lack of household electricity.
Recommendations for Lay Reader and Policy Maker:
– Increase access to quality healthcare services, particularly for home deliveries, to reduce neonatal deaths.
– Improve vaccination coverage to reduce non-neonatal deaths.
– Promote family planning to reduce the risk of child mortality.
– Address socioeconomic factors such as household size and lack of household electricity that contribute to childhood deaths.
– Strengthen community health worker programs to provide education, case finding, and linkages to health facilities for prenatal care and other medical services.
Key Role Players:
– Ministry of Health (MOH)
– Partners In Health/Inshuti Mu Buzima (PIH/IMB)
– Community health workers (CHWs)
– General nurses at health centers
– General practitioners and nurses at district hospitals
Cost Items for Planning Recommendations:
– Training and capacity building for healthcare providers and community health workers
– Infrastructure improvement for health facilities
– Vaccination programs and supplies
– Family planning services and contraceptives
– Community education and awareness campaigns
– Monitoring and evaluation systems for tracking progress and impact

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong because the study conducted a matched case-control study and used verbal social autopsy to identify causes and risk factors for childhood mortality in Rwanda. The study also used InterVA4 to determine probable causes of death and cause-specific mortality fractions. The sample size of 618 deaths provides a substantial amount of data. However, to improve the evidence, the abstract could include more information about the methodology, such as the selection criteria for cases and controls, the data collection process, and the statistical analysis methods used. Additionally, providing information about the limitations of the study would further strengthen the evidence.

Background: Rwanda has dramatically reduced child mortality, but the causes and sociodemographic drivers for mortality are poorly understood. Methods: We conducted a matched case-control study of all children who died before 5 years of age in eastern Rwanda between 1st March 2013 and 28th February 2014 to identify causes and risk factors for death. We identified deaths at the facility level and via a community health worker reporting system. We used verbal social autopsy to interview caregivers of deceased children and controls matched by area and age. We used InterVA4 to determine probable causes of death and cause-specific mortality fractions, and utilized conditional logistic regression to identify clinical, family, and household risk factors for death. Results: We identified 618 deaths including 174 (28.2%) in neonates and 444 (71.8%) in non-neonates. The most commonly identified causes of death were pneumonia, birth asphyxia, and meningitis among neonates and malaria, acute respiratory infections, and HIV/AIDS-related death among non-neonates. Among neonates, 54 (31.0%) deaths occurred at home and for non-neonates 242 (54.5%) deaths occurred at home. Factors associated with neonatal death included home birth (aOR: 2.0; 95% CI: 1.4-2.8), multiple gestation (aOR: 2.1; 95% CI: 1.3-3.5), both parents deceased (aOR: 4.7; 95% CI: 1.5-15.3), mothers non-use of family planning (aOR: 0.8; 95% CI: 0.6-1.0), lack of accompanying person (aOR: 1.6; 95% CI: 1.1-2.1), and a caregiver who assessed the medical services they received as moderate to poor (aOR: 1.5; 95% CI: 1.2-1.9). Factors associated with non-neonatal deaths included multiple gestation (aOR: 2.8; 95% CI: 1.7-4.8), lack of adequate vaccinations (aOR: 1.7; 95% CI: 1.2-2.3), household size (aOR: 1.2; 95% CI: 1.0-1.4), maternal education levels (aOR: 1.9; 95% CI: 1.2-3.1), mothers non-use of family planning (aOR: 1.6; 95% CI: 1.4-1.8), and lack of household electricity (aOR: 1.4; 95% CI: 1.0-1.8). Conclusion: In the context of rapidly declining childhood mortality in Rwanda and increased access to health care, we found a large proportion of remaining deaths occur at home, with home deliveries still representing a significant risk factor for neonatal death. The major causes of death at a population level remain largely avoidable communicable diseases. Household characteristics associated with death included well-established socioeconomic and care-seeking risk factors.

This study was conducted in two rural Eastern Province hospital catchment areas covering approximately 529,000 individuals. In this intervention area, the Ministry of Health (MOH) facilities have been financially and technically supported by the non-governmental organization Partners In Health/Inshuti Mu Buzima (PIH/IMB) since 2005. In Rwanda, the health system includes three main levels: community, health center, and district hospital. Community health workers (CHWs) provide household level health education, case finding for acute and chronic illness, community IMCI (including diagnosis and treatment of pneumonia, diarrhea, and malaria), female contraception, and linkage to health facilities for prenatal care, deliveries, and other medical services [13]. Each of the 23 health centers serve a catchment area of approximately 20,000–30,000 people and are staffed by general nurses who provide basic diagnostics, outpatient acute services, family planning, prenatal care, and routine deliveries. The average walking distance from households to the nearest health facility is estimated at just over an hour in Kayonza and over an hour and a half in Kirehe [14]. Reflecting national standards, district hospitals in Eastern Province are staffed by general practitioners and nurses who provide secondary care for advanced or inpatient care for patients referred from health centers, including comprehensive obstetric emergencies requiring cesarean section, neonatal care, and inpatient treatment for severe childhood illness and severe malnutrition. We conducted a matched case-control study of all children who died before 5 years of age in the study area between 1st March 2013 and 28th February 2014. We identified deaths using multiple sources including facility registers, community health worker reports, monthly review of CHW-held community death records, and a database from a mobile phone-based reporting system, the Monitoring of Vital Events using Information Technology (MoVe-IT), which was introduced in these two districts in 2012 to improve vital events reporting [15]. After confirming childhood deaths with local CHWs, we conducted interviews with caregivers of the deceased child in their households. Trained data collectors approached caregivers between three weeks to one year following the child’s death. Each case was matched to two controls selected from the nearest households with a child in a comparable age group (for neonates, children aged 1–30 days; for infants, children aged 31 days up to 1 year; and for children older than one year, matched to those between 1 and 5 years) to the deceased child. Neonatal cases without an available control under 30 days of age were matched with infants up to 180 days of age. Prior to the VSA, interviewers asked families of neonatal deaths additional questions in order to screen out potential cases of stillbirth. We obtained written informed consent from the caregivers of the deceased children and those selected as controls. The current caregiver of the child was not necessarily the biological mother if the biological mother was not available or was deceased. Using a questionnaire based on the 2012 World Health Organization verbal autopsy (VA) tool [16] supplemented with questions from the Rwanda MOH’s Under-5 Death Audit Tool and the 2010 Rwanda Demographic and Health Survey, we obtained information on the case or control child’s demographic characteristics, information on the child’s birth, illness, care seeking, and the family’s perceptions of care. We used InterVA4 [17] to determine probable causes of death and cause-specific mortality fractions (CSMF) for each cause of death. The InterVA algorithm uses a range of health indicators taken from interviews as input and applies Bayes’ Theorem to determine the likeliest cause of death. The CSMF is an output from the algorithm and can be interpreted as the total number of deaths attributable to a specific cause. Prevalence of HIV and malaria were entered as “high” in the InterVA model, based on national level facility reporting indicating an estimate of greater than one in 100 deaths due to each of these diseases [18]. We estimated odds ratios for a range of child, caretaker, household, and care-seeking characteristics using conditional logistic regression. We retained variables with p-value less than or equal to 0.2 significance level in the univariate analyses in a multivariate model. We performed multiple imputations to infer values of missing data, which were considered missing completely at random. We used a bidirectional elimination stepwise method, which uses both forward selection and backward elimination in succession to determine optimal variables, to arrive at a final model in which the remaining variables were significant at the α = 0.05 level. Risk factors with potential collinearity were not included in multivariate analysis. We analyzed deaths in neonates (day of life 0 to 28) and non-neonates (day of life 29 to 5 years) separately. We used Global Burden of Disease level 1 categories [19] to organize causes of death by communicable, maternal, neonatal, and nutritional disorders (Group 1), non-communicable diseases (Group 2), and injuries (Group 3). This study was approved by the Rwanda National Ethics Committee and Partners Institutional Review Board under the Population Health Implementation and Training program, a partnership between PIH/IMB, the University of Rwanda, and the Rwanda MOH. All caregivers who participated provided informed consent and were informed that they were able to discontinue participation at any time during the interview.

Based on the provided description, here are some potential recommendations for innovations to improve access to maternal health:

1. Strengthening Community Health Worker (CHW) Programs: Enhance the training and capacity-building of CHWs to provide comprehensive maternal health services, including prenatal care, deliveries, and postnatal care. This can involve providing them with updated knowledge and skills, as well as necessary tools and resources.

2. Mobile Phone-Based Reporting System: Expand the use of mobile phone-based reporting systems, such as the Monitoring of Vital Events using Information Technology (MoVe-IT), to improve the reporting of vital events related to maternal health. This can help in timely identification of maternal deaths and enable prompt response and intervention.

3. Improving Access to Health Facilities: Address the geographical barriers by improving transportation infrastructure and increasing the number of health facilities in rural areas. This can include establishing more health centers and ensuring that district hospitals are adequately staffed and equipped to provide comprehensive obstetric care.

4. Enhancing Maternal Education and Family Planning: Implement targeted interventions to improve maternal education levels and promote family planning methods. This can involve community-based education programs, counseling services, and access to a wide range of contraceptive methods.

5. Addressing Socioeconomic Factors: Develop strategies to address socioeconomic factors that contribute to maternal mortality, such as poverty, lack of household electricity, and inadequate vaccinations. This can involve implementing social protection programs, improving access to basic amenities, and promoting immunization campaigns.

6. Strengthening Health Information Systems: Enhance the use of health information systems to collect, analyze, and disseminate data on maternal health outcomes. This can help in identifying trends, monitoring progress, and informing evidence-based decision-making for maternal health interventions.

7. Promoting Collaboration and Partnerships: Foster collaboration between the Ministry of Health, non-governmental organizations, and other stakeholders to pool resources, share best practices, and coordinate efforts to improve access to maternal health services. This can involve establishing multi-sectoral platforms and networks for knowledge exchange and joint planning.

It is important to note that these recommendations are based on the information provided and may need to be tailored to the specific context and needs of the target population.
AI Innovations Description
The study titled “Causes of death and predictors of childhood mortality in Rwanda: A matched case-control study using verbal social autopsy” provides valuable insights into the causes and risk factors for child mortality in Rwanda. Based on the findings of this study, the following recommendation can be developed into an innovation to improve access to maternal health:

1. Strengthening community-based healthcare: The study highlights the important role of community health workers (CHWs) in providing healthcare services at the household level. To improve access to maternal health, the innovation could involve training and empowering CHWs to provide prenatal care, promote safe deliveries, and educate mothers on family planning methods. This would ensure that pregnant women receive essential healthcare services in their communities, reducing the need for long travel distances to health facilities.

2. Mobile phone-based reporting system: The study mentions the use of a mobile phone-based reporting system called the Monitoring of Vital Events using Information Technology (MoVe-IT) to improve vital events reporting. Expanding and enhancing this system could be an innovative approach to improve access to maternal health. Through this system, pregnant women and new mothers could receive important health information, reminders for prenatal and postnatal visits, and access to teleconsultations with healthcare providers. This would enable timely and convenient access to healthcare services, especially for those living in remote areas.

3. Improving facility-based healthcare: The study identifies home deliveries as a significant risk factor for neonatal death. To address this, the innovation could focus on improving the quality and accessibility of facility-based healthcare services. This could involve upgrading health centers and district hospitals to provide comprehensive obstetric care, neonatal care, and treatment for severe childhood illnesses. Additionally, efforts could be made to reduce the average walking distance to the nearest health facility, ensuring that pregnant women have timely access to skilled birth attendants and emergency obstetric care.

4. Addressing socioeconomic and care-seeking risk factors: The study highlights the association between household characteristics, such as household size, maternal education levels, and lack of household electricity, with child mortality. The innovation could involve implementing targeted interventions to address these socioeconomic and care-seeking risk factors. This could include initiatives to improve access to education, promote income-generating activities, and provide affordable and reliable electricity to households. Additionally, community awareness campaigns could be conducted to educate families about the importance of timely healthcare-seeking behaviors and the availability of maternal health services.

By implementing these recommendations as innovative interventions, access to maternal health in Rwanda can be improved, leading to a reduction in maternal and child mortality rates.
AI Innovations Methodology
Based on the information provided, here are some potential recommendations for improving access to maternal health:

1. Strengthening community health worker programs: Community health workers (CHWs) play a crucial role in providing health education, case finding, and linking pregnant women to health facilities for prenatal care and deliveries. Investing in training, supervision, and support for CHWs can help improve access to maternal health services.

2. Increasing availability and accessibility of health facilities: Ensuring that health centers and district hospitals are adequately staffed and equipped to provide comprehensive obstetric care, neonatal care, and treatment for severe childhood illnesses can help reduce maternal and child mortality. Additionally, efforts should be made to reduce the distance and travel time to the nearest health facility.

3. Promoting family planning services: Encouraging the use of family planning methods can help prevent unintended pregnancies and reduce the risk of maternal and child mortality. Access to a range of contraceptive methods should be made available and accessible to women and couples.

4. Improving vaccination coverage: Adequate vaccinations can protect children from preventable diseases and reduce the risk of mortality. Efforts should be made to ensure that all children receive timely and complete vaccinations.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define the indicators: Identify specific indicators that measure access to maternal health, such as the percentage of pregnant women receiving prenatal care, the percentage of births attended by skilled health personnel, or the percentage of women using modern contraception.

2. Collect baseline data: Gather data on the current status of the selected indicators in the target population. This can be done through surveys, interviews, or existing health records.

3. Introduce the recommendations: Implement the recommended interventions, such as strengthening community health worker programs, improving facility infrastructure, promoting family planning services, and enhancing vaccination coverage.

4. Monitor and evaluate: Continuously monitor the implementation of the interventions and collect data on the selected indicators. This can be done through routine health information systems, surveys, or targeted evaluations.

5. Analyze the data: Use statistical analysis techniques to compare the baseline data with the post-intervention data. This will help determine the impact of the recommendations on improving access to maternal health.

6. Interpret the results: Assess the findings to understand the extent to which the recommendations have improved access to maternal health. Identify any gaps or areas for further improvement.

7. Adjust and refine: Based on the results, make any necessary adjustments or refinements to the interventions to maximize their impact on improving access to maternal health.

8. Repeat the process: Continuously repeat the monitoring and evaluation process to track progress over time and make further improvements as needed.

By following this methodology, policymakers and healthcare providers can gain insights into the potential impact of different recommendations on improving access to maternal health and make informed decisions to prioritize and implement the most effective interventions.

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