Harnessing the power of the community to improve child survival
Authors: Cheryl A Moyer, Elizabeth Kaselitz
Journal: The Lancet Global Health (2018)

Each year, more than 5·5 million children younger than 5 years die, mostly from preventable causes.1UNICEF2018A—Monitoring the situation of children and women.https://data.unicef.org/topic/child-survival/under-five-mortality/Date: 2018Date accessed: April 5, 2018Google Scholar Although the number of officially reported under-5 deaths has declined in recent decades,1UNICEF2018A—Monitoring the situation of children and women.https://data.unicef.org/topic/child-survival/under-five-mortality/Date: 2018Date accessed: April 5, 2018Google Scholar issues remain regarding the accuracy of official statistics, because about 70% of the world's population lives in countries without complete birth and death registration.2Joos O Amouzou A Silva R et al.Strengthening community-based vital events reporting for real-time monitoring of under-five mortality: lessons learned from the Balaka and Salima districts in Malawi.PLoS One. 2016; 11: e0138406Crossref PubMed Scopus (10) Google Scholar In 2015, the births of nearly a quarter of all children younger than 5 years had never been registered,3UNICEF2018B—Monitoring the situation of children and women.https://data.unicef.org/topic/child-protection/birth-registration/Date: 2018Date accessed: April 5, 2018Google Scholar and only 40 of 194 countries reported high-quality cause of death data to WHO.4AbouZahr C Bratschi MW Muñoz DC et al.How can we accelerate progress on civil registration and vital statistics?.Bull World Health Organ. 2018; 96 (26A): 226Crossref PubMed Scopus (11) Google Scholar Even in countries with well established birth and death registration systems, community-based deaths are often overlooked.5UN Development ProgrammeHuman development reports: why birth and death registration really are "vital" statistics for development.http://hdr.undp.org/en/content/why-birth-and-death-registration-really-are-%E2%80%9Cvital%E2%80%9D-statistics-developmentDate: 2015Date accessed: April 5, 2018Google Scholar The paper by Merlin Willcox and colleagues6Willcox ML Kumbakumba E Diallo D et al.Circumstances of child deaths in Mali and Uganda: a community-based confidential inquiry.Lancet Glob Health. 2018; 6: e691-e702Summary Full Text Full Text PDF PubMed Scopus (30) Google Scholar in this issue of The Lancet Global Health reports on the use of community-based audits to identify all childhood deaths (including those who died outside health-care facilities) to ascertain likely causes and contributors to these deaths and to elicit recommendations for solutions to prevent future deaths. Notable findings include that three-quarters of the child deaths identified in two districts of Mali and nearly two-thirds of those in three districts of Uganda occurred outside a health-care facility and, therefore, would not have been included in official facility-based mortality audits. Even with an audit panel that included health-care providers and community members, cause of death was judged to be certain in less than 15% of cases. Panels were much more easily able to identify avoidable contributors to death than the precise medical cause of death. One or more avoidable factors were identified in 97% of cases in Mali and 95% of cases in Uganda. These findings raise two key issues. First, dare we ask, is understanding the clinical cause of death truly the most important factor in prevention efforts in low-resource settings? The results of the study by Willcox and colleagues6Willcox ML Kumbakumba E Diallo D et al.Circumstances of child deaths in Mali and Uganda: a community-based confidential inquiry.Lancet Glob Health. 2018; 6: e691-e702Summary Full Text Full Text PDF PubMed Scopus (30) Google Scholar suggest that identifying, understanding, and addressing community-based issues, such as malnutrition and neglect (that might be an initiating factor that ultimately leads to a child's death from various medical causes), might be as important as identifying the precise physiological mechanism that led to death. This is not to say that knowing the clinical cause of death is irrelevant or that research that relies on verbal and social autopsy to understand the clinical cause of death and the social contributors is insufficient. Both are extremely valuable. Indeed, there is an increasing push in social autopsy research to include in-depth qualitative narratives to derive a deeper understanding of the events that transpired before death,7Moyer CA Johnson C Kaselitz L Aborigo R Using social autopsy to understand maternal, newborn, and child mortality in low-resource settings: a systematic review of the literature.Glob Health Action. 2017; 10: 1413917Crossref PubMed Scopus (19) Google Scholar, 8Moyer CA Aborigo RA Kaselitz EB Gupta ML Oduro A Williams J PREventing Maternal And Neonatal Deaths (PREMAND): a study protocol for examining social and cultural factors contributing to infant and maternal deaths and near-misses in rural northern Ghana.Reprod Health. 2016; 13: 20Crossref PubMed Scopus (12) Google Scholar thus supplementing what is found by verbal autopsy and uncovering some of the unexpected avoidable factors that Willcox and colleagues sought to identify in their research. However, the real question is, given finite resources, are prevention efforts likely to be more successful if aimed at individual, disease-specific risk factors or at community-identified risk factors that predispose children to various illnesses? The second issue that this manuscript raises relates to the enormous value of including community members in assessments of child mortality and initiatives to improve outcomes. Community members readily recognise factors that put children at risk of death that would rarely surface in provider-led, facility-based audits. Community members are often those closest to solutions but farthest from the power structures that can drive change. If the global community is serious about reducing child mortality, this reality needs to change. The chasm between health-care facilities and the communities they serve needs to be bridged,9Hill E Hess R Aborigo R et al."I don't know anything about their culture": the disconnect between allopathic and traditional maternity care providers in rural northern Ghana.Afr J Reprod Health. 2014; 18: 36-45PubMed Google Scholar and providers need to see community members as allies in the fight for child survival rather than the source of the problem. Indeed, our work in Ghana suggests that communities empowered with data about maternal and neonatal deaths in their communities welcome the opportunity to develop and implement their own, local solutions.10Kaselitz E Aborigo R James K Agorinya I Williams J Moyer CA Using community-driven solutions to improve maternal and neonatal outcomes in rural northern Ghana: the PREMAND project.Lancet Glob Health. 2018; 6: S13Summary Full Text Full Text PDF Google Scholar The findings from Willcox and colleagues suggest that one valuable next step would be to design and implement a multisite research study to show whether community-based audit panels can lead to interventions that ultimately improve under-5 mortality outcomes. It is one thing to identify community-based contributors to mortality, but it is another to effectively intervene on them. Although the findings published here indicate enormous potential for improved outcomes by more meaningfully engaging the community, more data are needed to ascertain if such potential can be truly realised and how that might be accomplished. Regardless, Willcox and colleagues' findings are a validation that genuine partnerships with communities are likely to pay dividends, something that public health practitioners have long known but struggled to broadly implement. This paper shows not only that community engagement is feasible, but also that local expertise is crucial to identify and address the most actionable contributors to death. We declare no competing interests. Circumstances of child deaths in Mali and Uganda: a community-based confidential enquiryLocal investigation and review of circumstances of death of children in sub-Saharan Africa is likely to lead to more effective interventions than simple consideration of the biomedical causes of death. This approach discerned local public health priorities and implementable solutions to address the avoidable factors identified. Full-Text PDF Open Access