Magnitude and Determinants of Under-Five Mortality and its Association with Maternal Mental Distress in Gamo Gofa Zone, Ethiopia
Creators: name: Temam, Girma
Publisher: name: National Academic Digital Repository of Ethiopia
Year: 2017

description: Background: Although there is documented reduction in under-five mortality in the country (Ethiopia), the mortality rates are still high that about one in every 21 Ethiopian children die before their first birthday and one in every 15 children die before their fifth birthday. Besides, it is clear that efforts should be continued to sustain the reduction of mortalities to achieve the newly endorsed sustainable development goals (SDGs) target. The death of a child is one of the most stressful events that a mother may experience during the course of her lifetime and may lead to sustained mental health effect. Studies investigating post child loss maternal mental health status in developing countries, particularly in Ethiopia are rare. There are inconsistencies with regard to determinants of under-five mortality found by few previous studies. As Demographic Surveillance System (DSS) sites are becoming sources of evidence for magnitude and cause of mortalities in areas where vital event registrations are lacking (especially in Africa, Asia and Oceania), mortality rates in such sites in comparison with non-DSS areas need to be investigated. As the Arba Minch DSS is new, mortality studies in general and determinants of under-five mortality and its relation with maternal mental distress in particular are limited. All these call for investigating determinant factors of childhood mortality and its effect on maternal mental wellbeing to strengthen existing ones and design new interventions gearing to the specific context/community for sustained reduction of mortality and improvement of maternal mental well-being for attainments of maternal and child health related targets of SDGs. Objective: To assess the magnitude and determinants of under-five mortality and its association with maternal mental distress in Gamo Gofa Zone, Southern Nations, Nationalities and People's Region, Ethiopia. Methodology: Mixes of methods were utilized to address each of the specific objectives. Accordingly, prevalence (simple cross-sectional) study- to assess the prevalence of childhood mortality, matched case control (deceased under-five children as cases and two live under-five children as matched controls) - to determine determinants of under-five mortality and comparative cross-sectional (mothers with child death as exposed and two mothers with live child as matched unexposed) - to determine the effect of child death on maternal mental health were implemented. The study took place in 2014. The study populations were under-five xi children and their respective mothers. For the prevalence study, a census of selected kebeles (the smallest administrative units) was conducted and additional data from the Arba Minch DSS database were identified. Accordingly, a total of 20,161 under-five children were identified and included for the prevalence analysis. A total of 381 cases and 762 controls for the case control study were included. For the comparative cross sectional study, 356 exposed and 712 unexposed were included. Maternal mental distress was assessed with the World Health Organization's (WHO's) self-reporting questionnaire (SRQ-20). Data were entered using Epi Info Version 3.5.1 and analysis was performed by open-epi version 2.3 and STATA 11 as appropriate. In all cases, weighted analysis was conducted to account for unequal selection probability. Chi-square with the corresponding p-value was determined to assess bivariate association between the dependent and the independent variables for the first objective. Extended Mantel-Haenszel chi-square for linear trend was performed to assess presence of linear trend in under-five mortality and maternal mental distress. Bivariate and multivariable conditional logistic regression was applied to assess predictors of under-five mortality and maternal mental distress. Result: The overall weighted under five, infant and neonatal mortalities with their corresponding 95% confidence intervals were: 42.76(39.56-45.97), 33.89(31.03-36.76) and 18.68(16.53-20.83) per 1000 live births, respectively. Majority (82%) of neonatal deaths occurred within the first seven days of life. Under-five mortality was found to be significantly higher among non-DSS rural kebeles (52/1000 live births) and overall rural kebeles (43.1/1000 live births). Maternal education of grade nine and above (adjusted odds ratio (AOR) of 0.34(0.16-0.72)), maternal marital status of separated/divorced or widowed (AOR of 3.60(1.23-10.47)) and paternal occupation of daily laborer (AOR of 2.34(1.29-4.23)) were distal factors significantly associated with under-five mortality. Lack of a separate kitchen for cooking was environmental contamination related factor that was significantly associated with under-five mortality (AOR of 1.77(1.16-2.70)). Among maternal and child related factors: previous birth interval (AOR of 0.48(0.28-0.82) for 24-36months and AOR of 0.46(0.26-0.79) for more than 36 months), history of child death before the index child (AOR of 1.97(1.07-3.61)), being multiple birth (AOR of 13.72(5.26-35.79)) and live birth after the index child (AOR of 5.06(2.80-9.16)) were significantly associated with under-five mortality. Among personal illness control related factors: lack of post natal care (AOR of 2.27(1.25-4.11)), immunization status of the child (AOR of xii 3.62(2.02-6.50) for partially immunized and AOR of 11.02(5.16-23.53) for not immunized) and lack of vitamin A at least once after six months of age (AOR of 7.61(4.72-12.26)) were significantly associated with under five mortality. Lack of breastfeeding (AOR of 8.09(4.08-16.05)) and delaying of first bath after birth (AOR of 0.50(0.34-0.73)) were also significantly associated with under-five mortality. Unexpectedly, factors such as place and assistant of delivery were not significantly associated with under-five mortality. Mothers who lost their children had significantly high rate of mental distress than their counterparts (AOR of 1.84(1.11-3.04). Similarly, mothers with child loss reported a significantly high rate of suicidal ideation (23.3%), p-value of 0.003. Conclusions and Recommendations: Mortality rates identified in the current study are lower than other previous reports in the country. Significant number of children died during their early days of life. Socioeconomic factors like maternal education, husband occupation and marital status of mothers are shown to significantly affect childhood mortality. Factors such as having separate kitchen, post natal care, long birth interval, delaying first bath after birth, immunization and supplementation of vitamin A for children older than six months were among proximate factors which were significantly associated with low under-five mortality. Significantly high proportions of women with child loss were suffering from mental distress compared to those without child loss, including higher rate of suicidal attempts. Strengthening of maternal and child health interventions during pregnancy, delivery and postnatal period is recommended in order to mitigate majorities of neonatal mortalities that occur during early day of life. Investing on maternal education by targeting those at risk is crucial and may help to avert majority of childhood mortality. In order to maintain reduction of childhood mortality beyond post millennium development goals and attain the newly endorsed SDGs' targets, promotion of having a separate kitchen and strengthening of maternal and child health interventions, such as post natal care, family planning, immunization and supplementation of vitamin A for children older than six months is highly recommended. Screening of maternal mental health problems by incorporating simple common mental distress assessing tools such as SRQ into the maternal and child health care programs of health facilities, that is guided by stronger local evidences may have significant effect in reducing the impact of maternal mental health problems in the community.