Prioritizing Health Care Strategies to Reduce Childhood Mortality
Authors: Madewell Zachary J. , Whitney Cynthia G. , Velaphi Sithembiso , Mutevedzi Portia , Mahtab Sana , Madhi Shabir A. , Fritz Ashleigh , Swaray-Deen Alim , Sesay Tom , Ogbuanu Ikechukwu U. , Mannah Margaret T. , Xerinda Elisio G. , Sitoe Antonio , Mandomando Inacio , Bassat Quique , Ajanovic Sara , Tapia Milagritos D. , Sow Samba O. , Mehta Ashka , Kotloff Karen L. , Keita Adama M. , Tippett Barr Beth A. , Onyango Dickens , Oele Elizabeth , Igunza Kitiezo Aggrey , Agaya Janet , Akelo Victor , Scott J. Anthony G. , Madrid Lola , Kelil Yunus-Edris , Dufera Tadesse , Assefa Nega , Gurley Emily S. , El Arifeen Shams , Spotts Whitney Ellen A. , Seib Katherine , Rees Chris A. , Blau Dianna M. ,   Child Health and Mortality Prevention Surveillance Network, Begum Ferdousi , Rahman Mohammad Mosiur , Kamal Mohammed , Ahmed A.S.M. Nawshad Uddin , Hoque Mahbubul , Lee Kyu Han , Tasnim Saria , Rahman Mahbubur , Shirin Tahmina , Khan Iqbal Ansary , Flora Meerjady Sabrina , Ahmed Dilruba , Zaman K. , Islam Kazi Munisul , Ahmed Mohammed Sabbir , Hossain Mohammed Zahid , Rahman Mustafizur , Parveen Shahana , Bari Sanwarul , Arjuman Farida , Islam Farzana , Islam Ferdousi , Oundo Joseph O. , Revathi Gunturu , Rogena Emily , Kuria Magdalene , Mitei Paul K. , Murila Florence , Verani Jennifer , Sanogo Doh , Kourouma Nana , Sissoko Seydou , Onwuchekwu Uma U. , Sidibe Diakaridia , Keita Tatiana , Kone Diakaridia , Tennant Sharon M. , Greene Carol L. , Johnson J. Kristie , Koka Rima , Fairchild Karen D. , Lako Sandra , Kaluma Erick , Pratt Samuel , Kosia Baindu , Fayorsey Ruby , Ramirez Rebecca Alkis , Philipsborn Rebecca P. , Garel Mischka , Salzberg Navit T. , Koplan Jeffrey P. , Breiman Robert F. , Ritter Jana M. , Gary Joy , Zaki Sherif R. (deceased) , Verani Jennifer R. , Witherbee Jacob , Liu Lucy , Nair Shailesh , Winchell Jonas M. , Temesgen Fikremelekot , Yeshi Melisachew Mulatu , Alemu Addisu , Ibrahim Alexander M. , Gure Tadesse , Orlien Stian , Ali Solomon , Edrid Yunus , Gizaw Mahlet Abayneh , Getnet Fentabil , Fentaw Surafel , Monjane Celso , Nhachungue Sheila , Menendez Clara , Bramugy Justina , Kindcardett Milton , Nhampossa Tacilta , Nhacolo Ariel , Munguambe Khátia , Vitorino Pio , Carrilho Carla , Fernandes Fabiola , Mocumbi Sibone , Maixenchs Maria , Hurtado Juan Carlos , Ordi Jaume , Valente Marta , Rakislova Natalia , Chitungo Dercio , Manhique Zara , Adam Yasmin , Lala Sanjay G. , Petersen Karen L. , Swart Peter J. , Hale Martin , Wadula Jeannette , Dludlu Noluthando , Solomon Fatima , Chawana Richard , Lombaard Hennie , Sorour Gillian , Ntuli Constance 
Published: October 2022

ImportanceAlthough child mortality trends have decreased worldwide, deaths among children younger than 5 years of age remain high and disproportionately circumscribed to sub-Saharan Africa and Southern Asia. Tailored and innovative approaches are needed to increase access, coverage, and quality of child health care services to reduce mortality, but an understanding of health system deficiencies that may have the greatest impact on mortality among children younger than 5 years is lacking.ObjectiveTo investigate which health care and public health improvements could have prevented the most stillbirths and deaths in children younger than 5 years using data from the Child Health and Mortality Prevention Surveillance (CHAMPS) network.Design, Setting, and ParticipantsThis cross-sectional study used longitudinal, population-based, and mortality surveillance data collected by CHAMPS to understand preventable causes of death. Overall, 3390 eligible deaths across all 7 CHAMPS sites (Bangladesh, Ethiopia, Kenya, Mali, Mozambique, Sierra Leone, and South Africa) between December 9, 2016, and December 31, 2021 (1190 stillbirths, 1340 neonatal deaths, 860 infant and child deaths), were included. Deaths were investigated using minimally invasive tissue sampling (MITS), a postmortem approach using biopsy needles for sampling key organs and fluids.Main Outcomes and MeasuresFor each death, an expert multidisciplinary panel reviewed case data to determine the plausible pathway and causes of death. If the death was deemed preventable, the panel identified which of 10 predetermined health system gaps could have prevented the death. The health system improvements that could have prevented the most deaths were evaluated for each age group: stillbirths, neonatal deaths (aged &amp;lt;28 days), and infant and child deaths (aged 1 month to &amp;lt;5 years).ResultsOf 3390 deaths, 1505 (44.4%) were female and 1880 (55.5%) were male; sex was not recorded for 5 deaths. Of all deaths, 3045 (89.8%) occurred in a healthcare facility and 344 (11.9%) in the community. Overall, 2607 (76.9%) were deemed potentially preventable: 883 of 1190 stillbirths (74.2%), 1010 of 1340 neonatal deaths (75.4%), and 714 of 860 infant and child deaths (83.0%). Recommended measures to prevent deaths were improvements in antenatal and obstetric care (recommended for 588 of 1190 stillbirths [49.4%], 496 of 1340 neonatal deaths [37.0%]), clinical management and quality of care (stillbirths, 280 [23.5%]; neonates, 498 [37.2%]; infants and children, 393 of 860 [45.7%]), health-seeking behavior (infants and children, 237 [27.6%]), and health education (infants and children, 262 [30.5%]).Conclusions and RelevanceIn this cross-sectional study, interventions prioritizing antenatal, intrapartum, and postnatal care could have prevented the most deaths among children younger than 5 years because 75% of deaths among children younger than 5 were stillbirths and neonatal deaths. Measures to reduce mortality in this population should prioritize improving existing systems, such as better access to antenatal care, implementation of standardized clinical protocols, and public education campaigns.