Child mortality in Africa and south Asia: a multidimensional research and policy framework
Authors: Rachel Wangari Kimani, Samwel Maina Gatimu
Journal: The Lancet Global Health (2022)

Globally, progress has been made to address the diagnosis and management of common and avoidable acute illnesses that contribute to child mortality. Nevertheless, regions across sub-Saharan Africa and south Asia continue to have the highest rates of mortality in children younger than 5 years, with most deaths occurring after discharge from health facilities, indicating a gap in care following hospitalisation.1Nemetchek B English L Kissoon N et al.Paediatric postdischarge mortality in developing countries: a systematic review.BMJ Open. 2018; 8e023445Crossref PubMed Scopus (30) Google Scholar, 2Wiens MO Pawluk S Kissoon N et al.Pediatric post-discharge mortality in resource poor countries: a systematic review.PLoS One. 2013; 8e66698Crossref Scopus (65) Google Scholar In a large, multicentre, prospective cohort study with high follow-up and robust data collection,3The Childhood Acute Illness and Nutrition (CHAIN) NetworkChildhood mortality during and after acute illness in Africa and south Asia: a prospective cohort study.Lancet Glob Health. 2022; 10: e673-e684Summary Full Text Full Text PDF PubMed Scopus (3) Google Scholar the Childhood Acute Illness and Nutrition Network enrolled 3101 children aged 2–23 months with acute illness from nine rural and urban hospitals across six sub-Saharan African and south Asian countries, and investigated mortality during the first 30 days of hospital admission and within 180 days of hospital discharge. Participants were divided into the following three cohorts according to their nutritional status, which was defined by anthropometry using mid-upper-arm circumference: no wasting, moderate wasting, and severe wasting or kwashiorkor. One in every ten children (350 [11·3%]) died, of whom two-thirds (234 [66·9%]) died within 30 days of hospital admission and half (168 [48·0%]) died within 180 days of hospital discharge. Furthermore, there was a disproportionately high mortality rate among children with severe wasting.3The Childhood Acute Illness and Nutrition (CHAIN) NetworkChildhood mortality during and after acute illness in Africa and south Asia: a prospective cohort study.Lancet Glob Health. 2022; 10: e673-e684Summary Full Text Full Text PDF PubMed Scopus (3) Google Scholar Despite receiving care as recommended by current WHO and national guidelines, most deaths were attributed to avoidable disorders, such as severe sepsis, pneumonia, diarrhoea, and malnutrition. This observation highlights the potential shortcoming of current practices, which focus on inpatient management of common syndromes but have limited outpatient guidance on community-based models for managing children following hospital discharge.4Tickell KD Denno DM Inpatient management of children with severe acute malnutrition: a review of WHO guidelines.Bull World Health Organ. 2016; 94: 642Crossref PubMed Scopus (28) Google Scholar Additionally, this finding emphasises the need for interventions that address the social determinants of child survival, besides the clinically evident illness. As the authors point out,3The Childhood Acute Illness and Nutrition (CHAIN) NetworkChildhood mortality during and after acute illness in Africa and south Asia: a prospective cohort study.Lancet Glob Health. 2022; 10: e673-e684Summary Full Text Full Text PDF PubMed Scopus (3) Google Scholar numerous psychosocial pathways link the risk of mortality to nutritional status and severity of illness. Evidence is clear that social determinants of health magnify post-discharge mortality through reduced access to health care and adequate nutrition, which creates a cycle of disease and malnutrition.5Noble CC Sturgeon JP Bwakura-Dangarembizi M Kelly P Amadi B Prendergast AJ Postdischarge interventions for children hospitalized with severe acute malnutrition: a systematic review and meta-analysis.Am J Clin Nutr. 2021; 113: 574-585Crossref PubMed Scopus (3) Google Scholar Underlying medical and nutritional status are syndromes of compounding adverse effects from the interaction of disease with a history of structural, social, and economic inequality.6Pickett KE Vafai Y Mathai M Small N The social determinants of child health and inequalities in child health.J Pediatr Child Health. 2022; 32: 88-94Summary Full Text Full Text PDF Scopus (3) Google Scholar Therefore, recognising and addressing the social determinants of child nutritional status is a crucial first step in lowering child mortality. Furthermore, although not explored in this study, it is necessary to identify the biomedical factors that contribute to the malnutrition that leads to post-discharge child mortality to present a complete picture of the problem and to develop effective interventions, particularly where progress appears to be stalled.7Njunge JM Gwela A Kibinge NK et al.Biomarkers of post-discharge mortality among children with complicated severe acute malnutrition.Sci Rep. 2019; 95981Crossref PubMed Scopus (27) Google Scholar Referring all discharged children for post-hospital evaluation to prevent relapse and for continuous monitoring is not feasible in resource-limited countries. Therefore, risk stratification is a potential tool for identifying children at high risk of mortality and for effectively allocating resources to children in greatest need.8Wiens M Kumbakumba E Larson C et al.Postdischarge mortality in children with acute infectious diseases: derivation of postdischarge mortality prediction models.BMJ Open. 2015; 5e009449Crossref PubMed Scopus (37) Google Scholar, 9Madrid L Casellas A Sacoor C et al.Postdischarge mortality prediction in sub-Saharan Africa.Pediatrics. 2019; 143e20180606Crossref PubMed Scopus (15) Google Scholar However, it is important to acknowledge that risk stratification alone should not be seen as a solution to an inherently more complex multidimensional and multisectoral issue. First, the discharge planning process needs to be strengthened and referral mechanisms that better identify and engage with children and families who need additional support need to be ascertained. Second, a weak health system foundation cannot support best practice interventions; therefore, primary and community health systems should also be strengthened to promote preventive services. Third, much more needs to be done to validate predictive models of post-discharge risk and the evidence-based interventions that reduce child mortality in the community setting. Finally, even the most conscientious risk-based resource allocation cannot eliminate a contagion from a neighbourhood or provide all the socioeconomic and institutional resources needed for children to thrive, possibly because living conditions supersede the impact of facility-based care. Hence, a suggested research approach would be to not only create and validate a risk predictive tool but also take the next step and integrate this tool into the current nurturing framework and comprehensive child programmes (eg, Integrated Management of Childhood Illnesses), which focus on health promotion across a continuum of care from community settings to health facilities. This approach would enable early detection of children at risk of mortality and would facilitate timely case management, while reducing misallocation of scarce resources due to over-referrals and the admission of uncomplicated cases, which can lead to overtreatment and adverse outcomes (eg, antibiotic resistance).10Brownlee S Chalkidou K Doust J et al.Evidence for overuse of medical services around the world.Lancet. 2017; 390: 156-168Summary Full Text Full Text PDF PubMed Scopus (417) Google Scholar Child mortality is a complicated issue that frequently involves mixed infections in the context of poor socioeconomic conditions and evolving pathogenesis. Although more prospective studies are needed, synergistic strategies addressing health inequity in a multipronged approach have the most potential in reducing child mortality.6Pickett KE Vafai Y Mathai M Small N The social determinants of child health and inequalities in child health.J Pediatr Child Health. 2022; 32: 88-94Summary Full Text Full Text PDF Scopus (3) Google Scholar We declare no competing interests. Childhood mortality during and after acute illness in Africa and south Asia: a prospective cohort studyAmong diverse sites in Africa and south Asia, almost half of mortality occurs following hospital discharge. Despite being highly predictable, these deaths are not addressed in current guidelines. A fundamental shift to a child-centred, risk-based approach to inpatient and post-discharge management is needed to further reduce childhood mortality, and clinical trials of these approaches with outcomes of mortality, readmission, and cost are warranted. Full-Text PDF Open Access