Mortality Study in : Investigating the Causes in Death for Children Under 5 Mortality Study in Guinea Investigating the Causes of Death in Children Under 5

Authors Renata Schumacher Eric Swedberg Mamadou Oury Diallo Damou Rahim Keita Henry Kalter Omrana Pasha

BASIC SUPPORT FOR INSTITUTIONALIZING CHILD SURVIVAL 1600 Wilson Blvd., Suite 300, Arlington, VA 22209 USA • Tel: 703.312.6800 • Fax: 703.312.6900 E-mail: [email protected] • Website: http://www.basics.org Mortality Study in Guinea Investigating the Causes of Death in Children Under 5

Authors Renata Schumacher Eric Swedberg Mamadou Oury Diallo Damou Rahim Keita Henry Kalter Omrana Pasha Abstract Save the Children, BASICS I, and the Guinea MOH conducted a study of mortality among children less than 5 years old in , Guinea, from October 1998 through September 1999. This report describes the results of a verbal and social autopsy that was used to investigate the deaths of 330 children under 5. The objectives of the study were to determine (1) causes and trends in mortality, (2) the relative importance of each step in the Pathway to Survival, and (3) the most appropriate interventions to reduce child mortality in Mandiana and other similar settings. The methodology for the study built upon tools and methods developed by BASICS and Johns Hopkins University.

Recommended Citation Schumacher R., E. Swedberg, M. O. Diallo, D. R. Keita, H. D. Kalter, and O. Pasha. 2002. Mortality Study in Guinea: Investigating the Causes of Death in Children Under 5. Published by Save the Children Federation, Inc. and the Basic Support for Institutionalizing Child Survival (BASICS II) Project.

Credit Photo credit: Save the Children.

Save the Children Save the Children is an international nonprofit child-assistance organization working in more than 45 countries worldwide, including the United States. Founded in 1932, its mission is to make lasting, positive change in the lives of children in need. Save the Children is a member of the international Save the Children Alliance, a worldwide network of 26 independent Save the Children organizations working in more than 100 countries to ensure the well-being and protect the rights of children everywhere. Save the Children aims to champion “finishing the unfinished child survival agenda” through advocacy and recognized leadership in child survival.

BASICS II BASICS II is a global child survival project funded by the Office of Health and Nutrition of the Bureau for Global Health of the U.S. Agency for International Development (USAID). BASICS II is conducted by the Partnership for Child Health Care, Inc., under contract no. HRN-C-00-99-00007-00. Partners are the Academy for Educational Development, John Snow, Inc., and Management Sciences for Health. Subcontractors include Emory University, The Johns Hopkins University, The Manoff Group, Inc., the Program for Appropriate Technology in Health, Save the Children Federation, Inc., and TSL.

This document does not necessarily represent the views or opinion of USAID. It may be reproduced if credit is properly given.

U.S. Agency for International Development (USAID) Office of Health and Nutrition Bureau for Global Health Website: http://www.usaid.gov/pop_health/

1600 Wilson Boulevard, Suite 300 54 Wilton Road Arlington, Virginia 22209 USA Westport, CT 06880 USA Tel: 703-312-6800 Tel: 1-800-728-3843 Fax: 703-312-6900 Website: www.savethechildren.org E-mail address: [email protected] Website: www.basics.org Chapter 4 Chapter 5 Chapter 2 Chapter 1 Acknowledgments Acronyms Table ofContents References Chapter 3 Results Discussion nrdcin...... Introduction Executive Summary ehdlg ...... Methodology Data AnalysisandIn Treatment andReferr ...... Quality ofCare Pathway toSu Causes ofDeath Demographic Characteristicsof Wellness Behaviors Description ofHousehold 13 oftheStudyPopulation...... Description Data Collection Comparison ofSample Health Situationin Mandiana andtheMinistry Save theChildrenProgra Causes ofDeath Rates...... Mortality Wellness Behaviors Conclusions and Methodology Limitations Pathway toSu Seasonal, Geographical,andAgeDistribution Selection ofStudyClustersand 9 Formative Research,AdaptationandField ...... Testing ofQuestionnaires,and Training Survey Objectives ...... vvlAayi ...... 19 ...... Analysis rvival vvlAayi ...... 41 ...... Analysis rvival ...... Recommendations ...... 17 ...... 39 ...... Guineaand ...... 15 ...... 37 ...... epeain...... 11 ...... terpretation al Recommendations Characteristics ...... 44 ...... m inG hrceitc ...... 13 ...... Characteristics of Healthin adaa...... 5 Mandiana...... ape...... 16 Sample...... ie ...... 3 ...... uinea Identification ...... 44 ...... 35 ...... Mandiana ...... 34 ...... fDah ...... 10 ...... of Deaths fDah ...... 40 ...... of Deaths ...... 4 ...... 31 .38 11 13 35 47 vii 3 9 v 1 6

iii TABLE OF CONTENTS iv TABLE OF CONTENTS Figures Tables Annexes Table 5.3 Primary Causesof Primary Table 5.3 38 ...... inGuinea Age-SpecificChildhoodMortality Table 5.2 of Comparison Vaccination Table 5.1 Provider’s Table 4.8 Ten MostFrequently MentionedReasonsfor NotGoingtoaHealthPost/Center Table 4.7 MostCommonReasonsfor Taking Child toHealthProvider, Table 4.6 26 ...... Care-seekingBehavior Panel) by CauseofDeath(asDefinedby theExpert Table 4.5 CausesofDeathAmongNeonates, Post-neonates, andChildren Table 4.4 Diagnosis Table 4.3 15 ...... ImmunizationStatusofChildrenwithHealthCards Table 4.2 iue41 Q Figure 4.10 ofDiagnosisGiven Comparison by Health Worker and Figure 4.9 Figure 4.8 Type of Home Treat Figure 4.7 MandianaP Figure 4.6 Figure 4.5 Figure 4.4 Age Figure 4.3 Mor Figure 4.2 Figure 4.1 The Figure 2.2 of Map Figure 2.1 ofthe Characteristics Table 4.1 GeneralInformationand Table 2.1 89 ...... Usedby thePanel Criteria Scoring toDetermine “Quality ofCare” E: Annex MedicalRecords Annex D: ne :Treatment and Annex C: SocialAutopsy Annex B: ne :Verbal A Annex A: rHsia...... 29 or Hospital...... Provider and SignsSymptomsMostFrequently by Observed Health 20 ...... Panel by theExpert (12–59 months)asDetermined xetPnl...... 33 ...... Panel Expert 24 ...... Distribution ofAllDeathsChildrenUnder5withMedical Records Causes ofDeathasDefined Place ofBirth Weight forAgeClassi uality AssessmentofCareProvid tality ofChildrenUnder5 Years Modified Pathway to Distribution ofDeaths utopsy Questionnaire ...... 27 ...... Guinea Grouped bySubprefecture Actions andPrescr twyt uvvl...... 21 ...... athway toSurvival Records Q om...... 69 ...... Form and Death btato om...... 79 ...... Abstraction Form ...... 4 ...... Child Mortality Child Mortality Population UnderSur etGvn...... 22 ...... ment Given iain...... 16 ...... fication Main HealthIndicatorsfor uestionnaire ...... 17 ...... Coverage (Children12–23Months uvvl...... 7 ...... Survival ...... 17 ...... pin ...... 30 ...... iptions ...... 49 ...... yEpr ae ...... 19 ...... Panel by Expert in Guinea yGne ...... 16 ...... by, Gender ...... 18 ...... ed by Health Wo ...... 71 ...... elac ...... 14 ...... veillance ...... 38 ...... una...... 6 ...... Guinea kr...... 34 ...... rker l)b ad.....36 ...... Old) by Card H World HealthOrganization WHO Traditional OfficeofPrivate and Voluntary healer Cooperation, Bureaufor Humanitarian USAID/BHR/PVC Traditional attendant birth USAID Sexually transmitted disease UNICEF U5MR Stateofthe World's Children TH Save theChildrenFederation Inc. TBA STD SOWC Oralrehydrationtherapy SC/US Oralrehydrationsalts Oralpoliovaccine MinistryofHealth PEV/SSP/ME Maternalandneonataltetanus ORT Knowledge,practices,andcoverage ORS JohnsHopkinsUniversity, SchoolofHygieneandPublic Health OPV MOH MNT Infant rate mortality KPC IntegratedManagement ofChildhoodIllness JHU Humanimmunodeficiencyvirus IV/IM Healthinformationsystem IRS Healthfacilityassessment IMR andtetanus pertussis, Diphtheria, IMCI HIV HIS DemographicandHealth Survey HFA DPT DPS BacilleCalmette-Guérin DPE DHS infection Acuterespiratory for InstitutionalizingChildSurvival BasicSupport CVS COGES BCG BASICS ARI Acronyms Response, U.S. Agencyfor Development International United StatesAgencyforInternational Development United NationsChildren'sFund rate Under-5 mortality et Primaires Santé de Soins Health CareandEssentialMedicines) Vaccination, de Elargi Programme Santé la de Intravenous/intramuscular Régional Inspecteur Santé la de Prefectoral l’Education de Directeur Préfectorale Direction Santé de Villageois Santé de Comité Gestion de Comité Médicaments Essentiels Médicaments (TheExpandedProgramfor Immunization,Primary (VillageHealthCommittee) (CommunityHealthManagementGroup) (RegionalHealthOfficeDirector) (DistrictHealthOfficeDirector) (DistrictEducationOffice)

v ACRONYMS

their encouragement and support for this study.their encouragement andsupport ElizabethKilbour,special thanksgotoPeter Halpert, andCathy Bowes for atUSAID/ We alsothanktheteamofmedicalextractors, Dr. CamaraandMr. Namory SidibéDaouda,and Mrs. AïssatouDiallo, Mrs. Beavogui, AnneMarie Mrs. Fanta Camara,andMs. MaimounaDiakite. indifficult circumstances:who accomplishedtheirwork Mrs. Fatoumata Dioubate(supervisor), Dr. Mamady Kourouma, inRegionalHospital pediatrician Dr. Camara, DPSSiguiri Siriman Dr. BocarDem,DPSKankan Dr. Diallo, MamadouOury SC/USMandiana Ms. AdamaDiop, nurse withSC/USMandiana Mr. AboubacarCamara, ChefdeCentreSantéMorodou,Mandiana Mr. Souleymane Diallo, Public Health Technician inMandiana Dr. Pascal DjibiCamara,HospitalDirectorinMandiana Mr. Sidibe, DirectorofMicro-projectsinMandiana Mr. ofSociologyattheUniversity MamoudouDioubate, ofKankan ChiefoftheDepartment Dr. OusmaneSow, IRSKankan We areespeciallygrateful panel: for ofthemembersexpert thework inMandiana). (pediatrician Mamadou AliouBarry Onivogui (DPEofMandiana),Saran Diakite(Directorof Women's ConditioninMandiana), andDr. GeneralofDecentralization),JeanNoel namelyBandianDoumbouya (Secretary support, Mandiana). Severalothertechnicalandadministrativeservicestheirstaffalsoprovided (SC/USProgram Representatives inGuinea), andDr.Anne Martin Amara Traore (DPSof chiefs, for for thisstudy. theirsupport their busyschedules.Ourthanksalsogototheleadersinthesevillages,notablyvillage village healthcommitteesandthemotherscaretakerswhosharedtheirexperiencesdespite this study. acknowledge theworkofnumerouspeopleandorganizationsthatcontributedtosuccess W Acknowledgments We tosincerelythanktheteamofdedicatedinterviewers wouldlike totaketheopportunity Our sincerethanksgotothemembersofLeadershipCommittee, Joyce Lemelleand We wouldfirstliketoofferourthanksthepeopleincommunities:membersof also inotherareasof West thatareconfrontedwithsimilarproblems. Africa We wishto alleviate thesufferingcausedbydeathofyoungchildrennotonlyinMandianabut e hopethatthisresearchwillimprovethehealthprogramsinMandianaandhelp vii ACKNOWLEDGMENTS

hospital cases.Mostchilddeaths,however, takeplaceinthehome, averages. InMandiana,deathstatisticsarederivedmainlyfrom while unknown,areexpectedtobehigherthanthesenational Child mortalityfiguresfortheruralandremoteMandianaprefecture, deceased children. Mostoftheinterviews were communities tointerviewthe caretakersofthe cases, andtheymortality traveled tothe The interviewteamwasinformed about statistics. andbirth clusters gatheredmortality committees andthehealth centersinthe30 personnel weretrained. Village health developed forthequestionnaires,andstudy Malinké. Computerdata-entryprogramswere adapted andtranslatedintothelocallanguage, formative research,studyquestionnaireswere 30 randomlyselectedvillages.Following conducted intoalldeathsofchildrenunder5in place inall73villages,researchwas in 1998. took surveillance While mortality villages thathadatotalpopulationof180,584 Guinea,consistingof73large northeastern inMandiana. mortality toreducechild interventions appropriate in thePathway andtoidentify toSurvival, ofeachstep estimate therelative importance trendsandcauses, to mortality determine investigationconducted amortality to (BASICS)Project,SaveSurvival the Children for InstitutionalizingChild the BasicSupport . and With localpartners projectin (MOH) toimplementachildsurvival the communitiesandMinistryofHealth understood. SavetheChildrenisworkingwith to asthePathway arepoorly toSurvival, care-seeking outsidethehome,oftenreferred addition, care-givinginsidethehomeand inthissetting.the causesofmortality In trendsand isknownand little aboutmortality T Executive Summary Mandiana isalargeprefecturein highest intheworld:98/1,000and177/1,000respectively1999. he infantandunder-5 mortalityratesinGuineaare amongthe one-half ofthe totalunder-5mortality. mortality, accountsfor andinfant mortality isaboutone-half of infant neonatal mortality is aboutone-halfofneonatal mortality, that inotherstudies. neonatalmortality Early The agedistributionofdeaths issimilarto meningitis/sepsis (4%),andmeasles(2%). malnutrition (6%),neonatalinfections(4%), asphyxia (7%).Othercausesofdeathare (15%), neonataltetanus (9%),andbirth acute respiratoryinfections(25%),diarrhea causes ofunder-5deathsaremalaria(32%), is 50/1,000.mortality The five mostcommon is47/1,000,andtheneonatal mortality is97/1,000,thepost-neonatal mortality is171/1,000,theinfant under-5 mortality approximate national-level statistics. The and upperGuineamoreclosely compare favorablywiththeratesforbothrural trendsinthestudyarea specific mortality the12-monthstudyperiod.during The age- the possiblecauseorcausesofdeath. autopsies andmedicalrecordstodetermine should beanalyzed,andreviewedtheverbal determined significantvariablesandhowthey recommendations onthequestions, data. panelmade The expert on amonthlybasistomonitorandreviewthe Mandiana hospitalandhealthcommunitymet social science,andothermembersofthe the University ofKankan’s of department representatives fromtheMinistryofHealth, death. Anexpert panelconsistingof conducted 1–2monthsafterthereported A totalof330caseswereinvestigated 1

1 EXECUTIVE SUMMARY 2 EXECUTIVE SUMMARY ■ strategies: suggest theneedtodevelopseveralnew the MOHandSC/USinMandiana of thecurrentprogrammaticinterventions recommendations thatbothaffirmthechoice ■ ■ this issue. attendants(TBAs)shouldaddress birth clean deliveriesbytrainingoftraditional immunization andcontinuingtopromote tetanus. Improvingtetanustoxoid of thesedeathswereduetoneonatal were inneonates,andthelargestnumber Almost one-thirdoftheunder-5deaths There arefivemajorfindingsand mechanisms toimprovethequalityof treatment shouldbeaddressedby received only“average”oreven“poor” of thechildrenwhocametofacilitiesbut The treatmentoutcomesofoverone-third level. appropriate treatmentatthecommunity insecticide-treated bednetuseand larger scalestrategiestoimprove be effectivelyaddressedbynewand under-5 deathwasmalaria,whichshould The largestcause(almostone-third)of other parts ofGuineaand other parts West Africa. results arepotentiallyapplicabletomany information forMandianaprefecture,the ■ ■ Although thisstudyprovidesspecific child illness. fundsforemergency transport severe expand theuseofobstetrical training oftraditionalhealersandto be addressedbystrategiestoimprovethe lack ofmoneytoaccesstreatmentshould preferred useoftraditionalhealersandthe appropriate care-seekingbecauseofthe seeking isalsoacriticalstep.Delaysin componentofcare- The resorting-to-care in thePathway toSurvival. of “danger”signscouldaddressthisstep improve caretakerrecognitionandlabeling behavior changecommunicationsto had thegreatestimpact.Anapproachof (61%), improvingcare-seekingcouldhave visited ahealthfacilitybeforetheirdeaths For thechildreninstudywhonever Illness) training. (Integrated ManagementofChildhood care, suchasfacility-basedIMCI Community SchoolsProject). Development [USAID/BHR/PVC])andaneducationproject(the Bureau forHumanitarianResponse,U.S.AgencyInternational Project, supportedby theOffice ofPrivateandVoluntary Cooperation, projects inMandiana:acommunityhealthproject(theChildSurvival in thecommunitygeneral.SC/USiscurrentlyimplementingtwo and lastingchangeinthelivesofchildrenwomenparticular Guinea, asinallcountrieswhereitworks,istohelpmakepositive )Knowledge,Practices,andCoverage 4) EmphasisBehaviors, the whichobserved 3) HealthFacility, whichevaluated thelevel 2) Organizational Life, whichexamined how 1) implementation. These studieswere asfollows: information toguideprogramdesignand baseline studiesthatprovidedawealthof the urbancommuneofMandiana. conducted inall12subprefectures,including the entireprefecture;itsactivitiesare information andservices. The projectcovers health care,vaccination,andfamilyplanning malaria/hygiene, nutrition,child/maternal Mandiana prefecture. Itsactivitiesinclude to improve andchildhealthin maternal S Save theChildren Program inGuinea Introduction and Survey andFood Frequency Assessment; home andcommunity levels; health carethatwastaking placeatthe behaviors ofcaretakersand lookedatthe training needsofthehealthagents; andthe of thehealthinfrastructures and theirhealthperceptions; the communitiesorganize themselves In 1997and1998,SC/UScompletedfive The goaloftheChildSurvivalProjectis Mandiana inMarch1997.ThefundamentalmissionofSC/US ave theChildrenFederation(SC/US)beganworkingin This information wouldpermitSC/USand the Survival notfoundinthefirst fivestudies. andsteps inthePathwayof mortality to investigation toprovideinformation oncauses benefit fromdeveloping amortality In 1998SC/USdecidedthat theprojectcould andchildhealth. aimed atimproving maternal activities inaccordancewiththeobjectives ofHealth,developedwith theMinistry other members oftheCVS. SC/US, incollaboration techniques, andtheirrolestasksas (including HIV/STDprevention), training hygiene-environment, family planning health,vaccination, malaria- maternal trained child/ CVSmembersinnutrition, the resultsofbaselinestudies, theproject the urbancommuneofMandiana. Basedon created inthe12subprefectures, including (CVS). Seventy-three CVSshave been created andtrainedvillagehealthcommittees Surveyoflocalnon-governmental 5) As abasisfor itscommunity SC/US work, are performing. health activitiesotherlocalorganizations the organizations, whichdetermined organizations andcommunity-based 2

3 INTRODUCTION 4 INTRODUCTION 1. approximately 2,400inhabitants) andsectors made upofdistricts(large villagesof subprefectures. population of180,584,isdividedinto12 2.1). MandianaPrefecture,witha1998 and onthesoutheastbyCôted’Ivoire(Figure prefecture ofKankan,ontheeastbyMali, prefecture isborderedonthewestby within theregionofUpperGuinea. The the easternedgeofRepublicGuinea The prefectureofMandianaissituatedon Health inMandiana Mandiana andtheMinistryof stepsinthepathway.critical causesofdeathandthemost important and limitedresourcestoaddressthemost MOH tomoreselectivelytargetinterventions Recensement General de la Population et de l'Habitat de et Population la de General Recensement Figure 2.1MapofGuinea 12° 10° Guinea-Bissau Gambia ATLANTIC OCEAN The 04 08 0 120 100 80 60 40 20 0 ATLANTIC Conakry OCEAN Sierra Leone Senegal KILOMETERS BISSAU GUINEA- Kamsar GUINEA Mauritania Boké Liberia 1 Boffa The subprefectures are subprefectures The 14° Conakry 14° GUINEE SENEGAL Mali Sangarédi d’Ivoire Fria Gulf of Guinea of Gulf Côte Dubréka Koundara Coyah MARITIME

Gaoual Faso Burkina Konkouré Forécariah

Télimélé Tondon Ghana Benty 8°

Kindia G

a

Lélouma m

b ia Kolenté MOYENNE GUINEE Pita Dalaba Labé Mali SIERRA LEONE SIERRA Frontieres internationales Frontieres residents International Boundaries ministeres des Limites Administrative RegionBoundaries Prefectures des Limites Prefecture Boundaries Prefectures residents Prefecture Capitals ministeres des Capitales Administrative RegionCapitals Capitale National Capital Fleuves Rivers 12° 12° Mamou Koubia . Dec. 1996. Conakry, Guinea: Bureau NationaldeRecensement. Tougué Dabola Bissikrima Kalinko Dinguiraye

Bafing period oflowfoodavailability causedbythe to September, thisregion experiences a cassava, yam,andrice.Each yearfromJuly fonio,products includepeanuts, corn, cotton, small-scale commerce.Principalagricultural on agriculture,traditionalminingofgold,and religion isIslam. The localeconomy isbased Forest regionethnicgroups. The dominant small populationsofPeulhs, Sousous, and inhabitants areMalinké,althoughthere the annualrainsturnroadstomud.Most difficult betweenJuneandNovemberwhen Kankan andMandiana(86km)isvery inaccessible areasofGuinea;travelbetween 6,000. The prefecture isoneofthemore seat, Mandiana,hasapopulationofabout prefecture has73villages. The administrative (small villagesorhamlets).Mandiana Faranah

Makona AT GUINEE HAUTE Kissidougou LIBERIA Guéckédou 0 8° 10° 10° Kouroussa

Tinkisso Didi Moribaya Macenta

Niger Niandakoro Kankan FORESTIERE GUINEE Nzérékoré Siguiri Yomou Nyagassola Kérouané

Sankarani Niger Beyla Lola Mandiana 8° MALI

D’IVOIRE CÔTE Sassandra 12° 10° 8° 3. 1999DHS. 2. 1999DHS. The healthagentsandthe Community Health pharmacist, andtwolaboratory technicians. through apharmacist,anassistant provides pharmacy-laboratoryservices gynecology throughmedicaldoctorsand general medicine, surgery, pediatrics, and prefectural hospital. The hospitalprovides prefectural healthdirector, managesthe hospital director, underthe whoserves assistants—run thesehealthstructures.A pharmacists, labtechnicians,andpharmacist doctors, healthaides,technical are also15healthpostsinruralareas. Essential Medicines(PEV/SSP/ME). There Immunization, PrimaryHealthCareand into thecountry’s ExpandedProgram for of theother11subprefectures,allintegrated Mandiana and11healthcenters,oneineach prefectural hospitalintheurbancommuneof health. Mandianaprefectureincludesa ofHealth,managesthedistrict’sthe Ministry employed bythegovernmentandrepresents health (DPS),whoisamedicaldoctor inGuinea.district The prefectural directorof daily dietaryneedsandcare-giving. each youngchildisresponsibleforhisorher motherof large Malinkéhouseholds, thebirth other elderfemalerelativesinmanyofthe While thereareco-wives, mothers-in-law, and the dailycareofchildrenunder5yearsold. family settings,mothersareresponsiblefor of food resourceswithinthefamily. Inmost roles ascaretakersofchildrenandmanagers school educationorhigher. primary education,and1.9%haveahigh women havenoschooling,only9.4%a schooling. InUpperGuinea,87.3%ofthe region have toenrollinformal opportunities unions arecommon. Few womeninthe extended kinshipunitsinwhichpolygynous before thecurrentyear’s cropisready. depletion ofthepreviousyear'sharvest Qualified healthagents—including Mandiana prefecturerepresentsahealth The populationiscomposedofpatrilineal, 2 Womenhavekey services. facility thatprovidesprenatalcare population liveswithin5kmofahealth In ruralareasofGuinea,only49.7%the modern servicesandbylowutilizationrates. has beenhamperedbythelackofaccessto nation's abilitytoimproveitshealthstatus facilities, equipment,andpersonnel. The system suffersamarkeddeficiencyof the BamakoInitiative,formalhealthcare improved considerablysincetheadoptionof access tohealthservicesatthelocallevel highest inthecountry. Nationwide, although poverty inUpperGuinea,at62%,was the approximately US$226. The prevalence of as anannualincomeperpersonof lived atorbelow thepoverty level, defined showed that53%oftheruralpopulation Ministry ofPlanningandCooperation Guinea conductedin1994–95bythe are slowly improving, astudyofpoverty in average. expected to behigherthanthenational for Mandianaprefecture,whileunknown,are U5MR) (UNICEF2001). figures Childmortality rate inthecountry(128.5IMRand221.9 world. UpperGuineahasthesecondhighest the U5MRinGuineaas17thhighest State of the World's Children World's the of State (Tableof 177/1,000live births 2.1). The 2001 rate(U5MR) andanunder-5mortality births rateinfant (IMR)of98/1,000live mortality The mostrecent(1999) Mandiana Health SituationinGuineaand health centers. in managementanddecisionmakingforthe represent thecommunity, actively participate Management Groups(COGES),which deaths occurathome.In1997, among147 mainly fromhospitalcases, althoughmost Health Survey Health Although economicconditionsinGuinea Death statisticsinMandianaarederived 3 (DHS) study reports anational (DHS)studyreports Demographic and Demographic (SOWC) ranks

5 INTRODUCTION 6 INTRODUCTION insufficient hygiene. knowledge, poverty, crowded housing,and customs, habits,foodtaboos,lackof contribute totheriskofbecomingill: measles, etc.).Manyotherfactors seasonal epidemics(e.g.,meningitis, placeinadditionto also holdanimportant rhino-laryngologic), parasites,andanemia Other pathologiessuchasinfections(oto- (ARIs), malnutrition,diarrhea,andmalaria. years oldareacuterespiratoryinfections dominant illnessesofchildrenlessthan5 Mandiana alsocomefromhospitaldata. The infants under7days old. the hospital,therewere19deaths(13.3%)of at 15 deaths(10.2%),andamong143births the MandianaPrefecturalHospital,therewere children lessthan5yearsoldhospitalizedat Table 2.1GeneralInformationandMainHealthIndicatorsforGuinea *** UNICEF ** 1999DHSestimates * UNICEF General characteristics ofthepopulation Other healthinformation Child healthindicators The knowncausesofillnessin Total populationofGuinea(1998) oa etlt ae5.5childrenborn/woman* population* deaths/1,000 17 population* births/1,000 42 births** live 666/100,000 births** live 48.4/1,000 births** live 222/1,000 births** live 129/1,000 births** live 177/1,000 births** live 98/1,000 Total fertility rate Crude deathrate Crude birthrate Maternal mortalityrate % ofpopulationwithaccesstohealthservices Upper Guineaunder-5mortalityrate Upper Guineainfantmortalityrate All Guineaunder-5mortalityrate All Guineainfantmortalityrate Neonatal mortalityrate Socioeconomic indicators Proportion ofthepopulationbetween0and14years State of the World's Children 2000 Children World's the of State State of the World's Children 1997 Children World's the of State oa dl ieayrt 50%male,22%female* 63% male, 34% female* 46%* % ofpopulationwithaccesstosafewater Primary schoolenrollmentratio Total adult literacy rate hrceitc Indicator Characteristics effective (Figure2.2). interventions gather theinformation neededtodevelop situationinMandianaand study themortality Barss 1990). This modelwas adaptedto Hopkins University (JHU)(Gray, Smith,and study weredeveloped by BASICSandJohns amortality and methodsfor undertaking Disease ControlandPrevention. The tools BASICS ProjectandtheU.S. Centersfor illnesses. This modelwas developed by the care-seeking for childrenwithsevere help examine theprocessofcare-givingand Pathway was toSurvival usedby thestudyto inMandiana.the highrates ofmortality The causesofandcontributors to most important community andtheDPSindetermining investigation wastoassistthelocal ofthechildmortality The purpose Survey Objectives 7,337,000 21%*** 51.5% 1 1 health posts,hospitals,andprivateclinics. Note: Informalhealthprovidersincludetraditionalhealersandfamilyelders;formalservices include publichealthcen Figure 2.2TheModifiedPathwaytoSurvival

Outside the home Inside the home elhIllness Health make referral to Providers hospital seeks outside Caretaker care Caretakers comply recommendations with treatment recognizes Family illness Informal only Informal and Formal only formal home care Caretaker provides gives quality Provider Survival care ters,

7 INTRODUCTION

Mandiana, arepresentative fromtheMicro- doctor fromtheprefectural hospitalin doctor fromtheDPS’office inMandiana,a Regional HealthOffice(IRS) inKankan,the panelincluded thedoctorfrom The expert US–Mandiana, andtheproject coordinator. DPS ofMandiana,arepresentativefromSC/ project andincludedarepresentativefromthe leadership/coordination committeeguidedthe several groupsinthecommunity. A clusters. years oldexpectedtooccurinthestudy total numberofdeathschildrenunder5 300 childdeaths,whichapproximatesthe for thestudy. This resultedinasamplesize of determine therequiredsamplesizeofdeaths expected associateddenominatorsto Survival andidentifiedkeyindicatorstheir examined thePathwayparticipants to would bemoreaccurate. The project networks sothattheresults death-reporting would allow toensurethequalityof efforts concentrated onthoseselectedclusters. This couldbe design wasthatthestudyefforts using clustersamplingwithalongitudinal village, was used. The mainadvantage of sampling, inwhicheachclusterwasanentire seasonality onthestudyfindings.Cluster examined inordertoreducetheimpactof (October 1998–September1999)were ofdeathsinthecommunity.reporting were involvedintheongoingdetectionand working withvillagehealthcommitteesthat costly thanasurveymodel,anditsupportedtheSC/USapproachof The teamselectedasurveillancemodelfortworeasons:itwasless collaborated todesignastudyprotocolandplanforimplementation. SC/US andtheMOHinKankantomortalitystudy. Theythen I Methodology Kalter, Dr. RenataSchumacher, andMs.MelisseMurrayoriented n July1998andwiththesupportofUSAID/Conakry, Dr. Henry SC/US establishedandcoordinated The deathsthatoccurredoveroneyear Dr. MohamedSylla. panelandthe collaboration withtheexpert protocol was developed andfinalized in and proposinginterventions. The study oftheresults, helping withtheinterpretation case, reviewingthemothers’narratives, determining thecausesofdeathforeach the caregiventochildrenbyhealthagents, appropriate carecriteria,judgingthequalityof health objectivesandindicators,determining panel’sexpert activities included identifying and adoctorfromSC/US–Mandiana. The from theUniversityofKankan,andanurse Realisation officeofMandiana,asociologist into French andthenadapted tothelocal health facility records. These were translated (Annex D)recordskeyinformation fromthe medical recordsabstraction questionnaire from healthcardsinthehousehold, andthe questionnaire (AnnexC)records information deceased children. The treatmentandrecords during interviewsofthecaretakers These twoquestionnaireswerecompleted actions takenduringthecourseofillness. autopsy questionnaire(AnnexB)examinesthe biological cause(s)ofdeath,andthesocial questionnaire (AnnexA)examinesthe investigation manual. The verbal autopsy English fromtheBASICS/JHUmortality Standardized questionnairesweredevelopedin Questionnaires, andTraining and FieldTesting of Formative Research, Adaptation Général Secrétaire of the Ministry ofHealth, oftheMinistry 3

9 METHODOLOGY 10 METHODOLOGY to localcaretakers ofchildren. The adapted accurate, comprehensible, andacceptable corresponding Malinkéterms were included inthequestionnaires andtheir Mandiana toensurethatthe phrases several villagesindifferentareasof Keita, inallphasesoftheactivity. participated local researchcoordinator, Mr. DamouRahim input screensinEpiInfo for theanalysis. The for theMinistryofHealth,prepareddata Mr. MasséCamara, anassistantresearcher abstractors, panelmembers. andexpert members), interviewers, medicalrecords systemandtraintheCVS death-reporting (toestablishanimators, the supervisors to GuineainOctober1998traintheSC/US returned Swedberg fromSC/US/Westport Eric subsequently reviewed clarification. for further discussion sessionsweretape-recordedand illnesses. Inmanycases,interviewsand useful forsolicitinglocaltermsusedchild the headofSaladouHealthCenter, were developed withtheinputofSC/USnursesand government healthinfrastructure.Casestudies, without thedifferenttypesofformal care-seeking behaviorsinareaswithand caretakers inminingzones,andtherangeof south oftheprefecture,practices and Malinké languagespoken inthenorth considerations includingthedifferencesin research activitieswasbasedonanumberof authorities. Selectionofthesitesforformative health workers,drugvendors,andlocal members, traditionalhealers,government six months,villagehealthcommittee who hadsufferedachilddeathintheprevious mothers ofchildrenunder5yearsold, discussions (focus,formal,andnatural)with interviews, free-listingtechniques,andgroup Research activitiesincludedin-depth research withSC/USandthelocalMOHstaff. ledtheformative sociology department assistant fromtheUniversityofKankan two months.Ms.MelisseMurrayandan conducting formativeresearchoveraperiodof cultural settingandlanguage(Malinké)by The studyinstrumentwaspretestedin Dr. Kalter, Dr. ClaudineJurkovitz, andMr. died. caretakers whosechildrenhadrecently field-tested innon-studyareaswith caretakers andtheinterviewers,theywere understood andusablebyboththe ensure thatthequestionnaireswereeasily questionnaires.intent oftheoriginal To ensure thattheyaccuratelyreflectedthe translated back intoFrench andEnglishto and translatedquestionnaireswerethen and thuscapturedinthestudy. system by the childdeathreporting reported assume thatnearlyallchild deathswere publicly.is mourned Therefore, theresearchers around 7daysofage),andthedeathachild Children arebaptizedduringinfancy(usually seem tobehiddenortaboodiscuss. village. particular that animators’serving reporters” “death then transmittedthisinformationtotheSC/US this networktotheCVSineachvillage,who bythan 5years oldwere membersof reported Pregnancies anddeathsofchildrenyounger incorporated intothedatacollectionnetwork. anddeathswerealso pregnancies, births, women whoaremostknowledgeableabout care providers. The clanleadersand “elder” attendants (TBAs),andothertraditionalhealth and religiousleaders, traditional birth members, healthpostsandcenters,village This villagenetworkincludedthelocalCVS developed ineachofthe30clustervillages. was andchilddeathreporting monitoring panel training.Anetworkofpregnancy theexpert sample wasconductedduring and Cooperation. The selectionofthecluster ofPlanning Census BureauoftheMinistry 1996 censusconductedby theNational topopulationfiguresfromthe proportionate selected by stratifiedrandom sampling SC/US. The 30villages(clusters)were villages ofMandianaprefecture by served The studypopulationincludedthe70largest Identification ofDeaths Selection ofStudyClustersand In this part ofGuinea,childdeathsdonot In thispart sensitivity tothepainfulsituationof nearby. Interviews were conductedwithgreat usually intherespondent’s householdor convenient totherespondent. This was conducted inMalinkéandatatimeplace ofthestudy.his orherwillingnesstobepart signedthestatementtoindicate participant participating. When consentwas obtained,the no adverseconsequencesfornot completely voluntaryandthattherewouldbe was made itclearthatparticipation respondent’s participation. The statement the respondentandrequested purpose, benefits,andrisksofthestudyto interview. the The statementdescribed was readtotherespondentbefore form appropriatetolocalcustomsandnorms caretaker. Aninformed consentstatementand when theycouldspeakwiththeprimary interviewers madeappointmentstoreturn respondent wasnotavailableonthefirstvisit, respondent. Ifthemostappropriate appropriate toincludemorethanone two ormorepeoplecaredforthechild,itwas his orherfatalillness).Insomecases,when (thechild’s caretakerinterview during primary most appropriaterespondentforeach schedule ofthehousehold,andidentified appropriate time,dependingonthework approached thehouseholdsat network.death-reporting Interviewers households by and thepregnancymonitoring given onthelocationof information inthe30villages.reported were Interviewers The projectstaffinvestigated alldeaths interviewers perteamandonesupervisor. oftwowork teamscomposedoftwo interviewers. the supported Onesupervisor and eachwas allocatedateamoftwo The 30clustersweredividedintotwozones, Data Collection During thestudy,During were allinterviews of caregiven atthehealthfacility. quality criteriatodeterminetheoverall death; thepanelalsousedpre-established autopsies toestablishthepossiblecauseof questionnaire withtheverbalandsocial held several meetingstoanalyze this information was panel gathered,theexpert and thetreatmentprescribed.Onceall medical provider, theestablished diagnosis, facility, by signsandsymptomsobserved the caretaker for thechildtohealth bringing about thechild,reasonsmentionedby the consultation, suchasgeneral information information onseveral aspectsofthe health facility. This questionnairecollected the medicalrecordsofchildrenseenata records abstraction form was filledoutfrom and otherservices. information regardingavailablehealthcare the interviewerofferedrespondent later time. Atthecompletionofinterview, interview wasinterruptedandcompletedata difficult torespondthequestions, the interviewand,ifcaretakerfoundittoo respondent. Condolenceswereofferedbefore analysis. Epi Info6.02wasusedtoconductdata medical careaccordingtorecords. care-seeking, andassessingthequalityof child, reviewingtheprocessofcare-givingand probable biologicalcausesofdeathforeach panel wasresponsiblefordeterminingthe Dr. Dialloenteredthedata. Oury The expert data inputfilesforthefourquestionnaires. Epi Info6.02andSPSSwereusedtodevelop Data AnalysisandInterpretation To completetheanalysis, themedical 11 METHODOLOGY

rivers, streams, andponds. The public pump uses water fromunprotectedsources suchas Guineainwhich43% of thepopulation rural sources. This comparesfavorably tomostof waterfromunprotected obtains drinking child illness. Only 9%ofthestudypopulation for determinant for areanimportant drinking cement inonly11%ofthehouses. (89%)withwood or floors aremainlyearthen of straw, andonly11%have roofsoftin. The deceased childrenlived have roofsmadeout Eighty-nine percentofhouseswherethe Housing andWater Characteristics Description ofHousehold largest population. fromDialakoro,is reported whichhasthe example, thelargestnumberofdeaths(22%) total populationofeachone(Table 4.1). For tothe subprefecture isroughlyproportional has beenlivingthereforlessthan4years. Mandiana withinthelast10years,and11.2% two percentofthepopulationhasmovedto than 10years (range: 10–90years). Twenty- stable; 79%hasbeenlivingtherefor more T Description oftheStudyPopulation Results from conductinginterviewsafterOctober1999. part ofGuinea;or(3)fundingconstraintsthatprevented theteam from thehome;(2)displacementorrelocation ofthefamilytoanother children becauseof(1)prolonged absenceofthechild'scaretakers children. Itwasnotpossibletointerviewthe caretakers of23the Interviews were conductedwiththecaretakers of330these Water sourcesfor washing andespecially The numberofdeathsidentifiedper The populationinMandianaisquite years inthesamplepopulationover1-yearstudyperiod. he studyidentified353deathsofchildren undertheageof5 of theinhabitantssharingjust oneroom. the houseattimechild died,with86% and in60%,five ormorepeople werelivingin three peopleshareaone-bedroom house, members. In66%ofthecases, morethan children and,toalesserextent, otherfamily mother, anddeceasedchild)areother in thehousehold(i.e., other thanthefather, Generally, mostofthe “other” people wholive the socioeconomicsituationofthesefamilies. sleeping canbeusedindirectlytovisualize household andthenumberofroomsusedfor of roomsinthecompound. the interviewers wrotedown the totalnumber room. Thus, itispossible thatinsomecases arranged inacircle,eachusuallywithone which consistofanumber ofhouses Mandiana areorganized in “compounds,” to 12rooms. This isbecause mostfamilies in thatsomeofthehouseholdshavereported up households haveonlyoneroom,interviewers factor forchildillness.Eventhough88%ofall about theextentofcrowdingandisalsoarisk (including thedeceasedchild)givesanidea washing anddrinking. The samesourcesofwaterareusedfor common sources(approximately30%each). and privateorpublicwellsarethemost The numberofpeoplelivingina The numberofpeoplelivinginonehouse 4 13 RESULTS 14 RESULTS 67% aremore than35years old. the menaremorethan25 years old,and (WHO1996). neonatalmortality early Mostof factorconsidered arisk for and perinatal years old; bothoftheseagerangesare and 29years old,and22%aremorethan34 three percentofthemothersarebetween 15 are much younger thanthefathers. Sixty- deceased children’s births. whether theirdeathswererelatedtothe fromthequestionnaire be determined wasconducted,butthe interview itcouldnot (3%). Onepercentofthemothersdiedbefore followed by fathers (6%)andgrandmothers mothers ofthedeceasedchild(88%), oftherespondents arethe The majority Father Characteristics oftheMotherand study includes only the deaths occurring in1year,study includesonlythedeathsoccurring ratewas calculatedasanestimate. theunder-5 mortality children (addtotheabove number6neonates, 6childrenfrom1-11months,and1112to59months). Even thought identified deceasedchildrenlessthan5years oldatthetimeofdeathweretaken. The calculationsarebasedonatotalof35 To the1-year rate, during andthetotaln thetotalnumberofrecordedlivebirths calculatetheage-specificmortality period oa 186–33–309 2142 92 livebirths livebirths livebirths 97 4 330 births 171/1,000 live – 6 353 – 91,806 4 mortality rates Calculated Total 14 4 Nyantanina 15 Mandiana Koundianakoro 3 Koundian 2,885 Kinieran Kantoumanina Dialakoro Balandougouba upeetr % # % # Subprefecture Table 4.1CharacteristicsofthePopulationUnderSurveillance The mothersofthedeceasedchildren 6412 72 22 024 20 28 72 22 77 29 26,401 surveillance ,2 4 13 8 14 3 5 7 13 2 16 7 1 11 14 9 4 14 2 6 8 29 8 9 16 9 14 4 11 9 6 2 29 7 7 32 5 35 4 8 21 9 8 14 28 3 10 7,980 7 30 6 30 6 2,620 23 36 10 5,886 10 21 7 9 9,066 34 7 5 5,997 30 32 8 4,145 23 7,182 11 9 4 9,811 3,945 31 6 5,888 Population under number of Number of Number number of identified etsdeaths deaths Total included in the study cases. Forwomen, thesecondmostcommon farms arementionedinonly 0.5%ofthe place intheirownfields,while cooperative with housework.Almostall farmingtakes respectively). Mostwomen combinefarming and fathers isfarming (95%and91% The mostcommonoccupationfor mothers Occupation and 0.6%offathers). education was notknown for 0.4%ofmothers educationorhigher.secondary (Thelevel of 4.8% ofthefathers having completed school,and0.6%ofthemothers primary 5.2% respectively having completedatleast respectively having noeducation, 4.2%and are similar, with94.8%and89.4% The mothers’ andfathers’ educationallevels Literacy < ot)mnh)months) months) (<1 month) 01004/,0 74/1,000 47/1,000 50/1,000 Neonatal deaths neonatal ot Child Post- 11 (12-59 (1-11 deaths umber of 3 he maternal age,withmostwomenbetween20 to increasesproportionally of childrenborn andneonatalmortality.perinatal The number factorage lessthan18years isarisk for time between theagesof15and19. Maternal Most mothersbecomepregnantfor thefirst Maternal ObstetricHistory other variables wasnotconstructed. between comparisons indicator for further educational level. Thus, asocioeconomic availability anduseofwater sources, and ofhouseconstruction, homogenous interms organization. percent ofthemothersbelongtoacommunity woodcutters (0.9%)werementioned. Thirty-six sellers (3%),technicians(2%),and (0.4%) andsellers(0.01%),forthemen, mentioned forthewomenarehousekeepers female occupation.Otheroccupations because nomenmentionit,thisisprimarilya occupation ismining(23%);evidently, Vaccine alvcie n7)32(46%) 37 (53%) (58%) 51 (58%) 51 allvaccines (n=70) (65%) 60 atthetimeofdeathandwith (71%) Children olderthan9months 67 Measles (n=70) with DPT1–3(n=88) (58%) Children olderthan3months 51 (58%) 51 (65%) DPT 3(n=88) 60 (69%) DPT 2(n=92) 66 DPT 1(n=95) (77%) 82 withOPV1–3(n=88) (68%) 72 Children olderthan3months OPV 3(n=88) OPV 2(n=92) OPV 1(n=95) 23(22%) OPV birth(n=106) BCG (n=106) No immunization(n=106) Children withHealthCards (n=106) Table 4.2ImmunizationStatus of The populationinthestudyisvery No. (%) Total recorded onthesehealthcards. following resultsarebasedontheinformation deceased child’s immunizationcard. The study, only106(32%)couldshow the Of the330caretakers interviewed for this Wellness Behaviors number ofchildrensurvivingis2.46. the studygroupis4.55,andaverage average towomenin numberofchildrenborn most having hadsixormorelive births. The who have hadfewer thantwolive with births, There were nowomen over theageof35 and 29yearsoldhavethreeormorechildren. Almost allofthewomen(97%)between25 and 24yearsoldhavingtwotofivechildren. However, exclusive breastfeeding ismuch children inthisstudywerebreastfed. According tothecaretakers, 91%ofthe Breastfeeding and only38%withadequate weight for age. lowwith very weight,41%withlow weight, neonatal groupisdramaticallydifferent:21% nutritional statusofthechildreninpost- weight).presumably hadlow birth The records lowweightforage(bothofthem lowcard recordsvery weight for age, andone a healthcardwas available, onlyonehealth age. these werenotedtohaveverylowweightfor ranged from12to23monthsold,and53%of children mostoftenaffectedbymalnutrition adequate weight for age(Figure4.1). The had low weightfor age, and43%had lowweightchildren hadvery for age, 31% on thehealthcardsshowed that26%ofthe The information onweight for agerecorded Growth Monitoring and older9monthsolder. vaccination coverageattheageof3months 4.2). There arenogenderdifferences infull cards hadnovaccinations recorded(Table Twenty-two percentofthechildrenwithhealth Immunization Of the12neonatesinstudyfor whom 15 RESULTS 16 RESULTS occurred inchildren lessthanoneyear old, months agegroup(Figure4.2). children inallagegroups,except the1–11 were male. There were moredeathsofmale Of the330childrenwhodied, 178(54%) Sample Demographic Characteristicsof still breastfeedingatthetimeofdeath. these childrendied,andmostofthemwere months. tonotethatallof Itisimportant is 13months, but themedianisonly4 months. The meandurationofbreastfeeding of breastfeeding, witharange of0to48 from ages1to6months. exclusivelyreported breastfeeding thechild milk, 86%responded“0months”,andonly4% many monthsdidtheirchilddrinkonlybreast less commonlyreported. When asked how Percent 100 Classification (n=72) Figure 4.1Weight forAge 10 20 30 40 50 60 70 80 90 0 Fifty-seven percentofthe deaths There isalargevariation intheduration Less than 1 month Very low weight for age(below –3z-score) Low weight for age(below –2z-score) Adequate weight for age(above –2z-score) 8.5 8.5 83 months 1–11 38 41 21 months 12–23 53 16 31 months 24–59 14 14 72 and only4%weretakentoahospitalatleast were takentoahealthcenterorpost, seeking behavior. Only39%ofthechildren health facility. This isdirectlyrelatedtocare- and6%ofdeathsoccurredina of births of alldeathsoccurredathome,andonly15% attended by morethanoneprovider). were attendant was44%(somebirths birth assistedby atraditional ofbirths proportion trained midwives attendedanother25%. The and workers attended38%ofthe births, were deliveredathome(Figure4.4).Health Eighty-four percentofthestudysubjects Place ofBirthandDeath cases. 59 monthsoldaccountedforonly22%ofall under 2yearsofage(78%).Children24to was concentratedinthegroupofchildren mortality. intheunder-5group The mortality was aboutone-halfofinfantmortality one-half ofneonatalmortality, andneonatal 4.3). was about neonatalmortality Early and 29%duringtheneonatalperiod(Figure with 28%duringthepost-neonatalperiod o ofdeaths No. 100 120 140 160 180 200 Under 5Years, byGender Figure 4.2MortalityofChildren χ 20 40 60 80 2 –4.4; 0 Eighty-four percent of all births and91% Eighty-four percentofallbirths Less than month 1 p -value =0.11 Total Female Male months 1–11 Age group months 12–59 Total infections (including meningitis,septicemia, deaths occurredinDecember 1998. Severe July 1999,whilemostdiarrhea/dysentery deaths duetoneonataltetanus occurredin 1999,andAugustFebruary 1999). Most peaks throughouttheyear (October1998, present several asmalaria, seasonal pattern from ARI,whilenotshowing ascleara inJulyoccurring andAugust 1999. Deaths withmostdeathsfrommalaria pattern, diseases. presentsaseasonal Malaria forbe observed themostcommoninfectious September 1999(63%). can Asimilarpattern October–November 1998andJuly– during therainyseason. including healthservices,forlongperiods be completelydeprivedofoutsidecontact, Communities aregenerallyisolatedandmay andOctobereachyear.occurs between April The areahasauni-modalrainyseasonthat higher temperaturesandalongdryseason. predominantly savannazonecharacterizedby Mandiana prefectureislocatedina Distribution ofDeaths Geographical andSeasonal facilities disaggregated bysex. deaths thatoccurredoutsidehealthcare There was nodifference inthenumber of from 0to60days), withamedianof2days. medical consultationwas3.5days(range mean durationofillnessbeforethefirst theillness leading todeath.once during The of Deaths Figure 4.3AgeDistribution Most ofthedeathsoccurredduring 43% Child (12–59months) (1–11 months)28% Post-neonate 29% Neonate (<1month) neonatal tetanusaccountedfor32%ofthe to under5years.Duringtheneonatalperiod, death ofneonatesandchildrenages1month for ageorverylowweightage. were reviewed(n=106),57%lowweight of thestudypopulationforwhomhealthcards was totheirdemise; prior however, inasubset nutritional statusoftheremainingchildren deaths (6%).Itisnotknownwhatthe Malnutrition wastheproximatecausein21 asphyxia, andothersevereinfections. of deathincludedneonataltetanus, birth and diarrhea(50deaths;15%).Othercauses This wasfollowedbyARI(83deaths;25%) accounted foratotalof104deaths(32%). cause ofdeathoverallwasmalaria,which As seeninFigure4.5,themostcommon Causes ofDeath of death. the geographic distribution ofthediagnoses curative healthservices. Table 4.3presents variation inthecoverage ofpreventive and subprefectures may tothe beattributed diagnoses ofdeathby thedifferent presenting onlysmallvariations. throughouttheyear,defined pattern and neonatalinfections)donotshowa cases died “on theway” tothehealthfacility. 8 and Note: 1caseismissingintheplace of birthdata, Figure 4.4PlaceofBirthandDeath Study cases 100 150 200 250 300 350 50 There isacleardifferenceinthecauseof differences inthedistribution of Important 0 276 oeHealth post/ Home 299 38 center 13 optlOther Hospital Place ofdeath Place ofbirth 13 8 2 2 17 RESULTS 18 RESULTS

Table 4.3 Diagnosis Grouped by Subprefecture

Diagnosis Subprefecture Kinieran Koundian Sansando Koundianakoro Balandougouba Dialakoro Mandiana Faralako Saladou Kantoumanina Morodou Nyantanina Total

Malaria 11 8 6 6 3 16 6 5 1 6 13 2 83 ARI 3 9 4 2 5 14 10 3 1 3 4 1 59 Neonatal tetanus 2 3 4 0 1 14 3 3 0 3 1 0 34 Severe infection 5 1 1 3 2 2 5 1 0 3 2 1 26 Diarrhea/ dysentery 2 4 2 2 5 2 1 1 1 3 0 2 25 Birth asphyxia 2 1 4 0 2 5 1 1 1 1 4 1 23 Malnutrition 2 0 0 1 1 6 4 0 3 2 0 2 21 ARI/diarrhea- dysentery 2 0 2 2 2 3 0 0 1 0 1 1 14 Malaria/diarrhea- dysentery 0 0 2 1 3 1 2 0 0 0 1 1 11 Other 0 0 2 1 2 3 2 0 0 0 1 0 11 Malaria/ARI 1 2 1 1 3 0 0 0 0 0 2 0 10 No possible diagnosis 0 0 1 0 1 2 1 0 0 2 0 0 7 Measles 0 0 0 2 0 4 0 0 0 0 0 0 6 Total 30 28 29 21 30 72 35 14 8 23 29 11 330 distinct groups whoguardchildren'swell- the Pathway thebehaviors toSurvival, oftwo group (Table 4.4). cause ofdeathin9%the casesforthisage wasMalnutrition identifiedastheprimary other diseasesin21%ofallcases. aloneor associatedwith diarrhea/dysentery present in31%ofthecases, followed by alone orassociatedwithotherdiseaseswas percentage becomes45%.ARI/pneumonia associatedwithotherdiseases, the malaria of alldeaths;whenaddedtodeathsfrom years aloneaccounted for old,malaria 36% given laboranddelivery. during other infections),probablyrelatedtothecare due tosevereinfections(tetanus,ARI,and Sixty-four percentofallneonataldeathswere (including meningitisorsepticemia)for22%. 24%, ARIfor10%,andothersevereinfections asphyxiadeaths inthisagegroup, for birth Figure 4.5CausesofDeathasDefinedbyExpertPanel In theconceptualframework knownas For childrenfrom1monthtounder5 R 18% ARI 9% Tetanus Neonatal 7% Asphyxia Birth 6% Malnutrition 8% Diarrhea/Dysentery Infection 8% Severe 4% Diarrhea/ARI 3% Malaria/Diarrhea 3% Malaria/ARI 2% Measles 6% Other 26% Malaria progressed. severity ofsymptomsasthedisease anincreasing number,reported variety, and signs orsymptomstheynoted, thecaretakers In responsetoopen-ended questionsabout the caretaker’s recognitionthatthechild isill. The firststepinthecare-seekingprocessis Illness andDangerSignRecognition Pathway toSurvivalAnalysis identified inthestudy. point inthepathwayare330children The denominatorsofthepercentagesateach deaths plottedalongthePathway toSurvival. Figure 4.6showsthedatafor330child and theallocationofresourceswithinthem. guide thecontentofchildhealthprograms Defining thebreakdownsinthismodelcan determinants forthedeathofchild. ofthe providers) areshown aspart being (thecaretakersandthehealth 19 RESULTS 20 RESULTS unconsciousness (38%). (41%), convulsions(38%), and normally (54%),fever(43%), fastbreathing neonates (n=97):stoppedbeing abletosuckle identified thefollowingsymptoms for Less than one month Neonatal tetanus 32% (31) 32% Percentageofthosewho died One monththrough Causeofdeath(n=330) tetanus Neonatal (Neonate) Less thanonemonth Age (12–59 monthsold)asDeterminedbytheExpertPanel Table 4.4CausesofDeathAmongNeonates,Post-neonates,andChildren 11 months ARI 28% (26) 28% 12 monthsthrough ARI (Post-neonate) 11 months 59 months (Child) ARI 16% (23) 16% ARI 59 months(Child) When prompted,thecaretakers n9)29% 10%(10) 9%(9) 3% (3) 8%(8) (23) 24% Malaria (n=97) No possiblediagnosis diagnosis Other (meningitis/septicemia) Severe infection ARI Neonatal infection Birth asphyxia n9)28% 4% (4) 4% (4) 2% (2) 1% (1) 2% (2) 3% (3) 1% (1) Malaria 2% (2) 4% (4) 3% (3) (n=92) No possiblediagnosis Other diagnosis Malaria anddysenteryordiarrhea Neonatal infection complications Measles withandwithout ARI anddysenteryordiarrhea Dysentery Diarrhea (meningitis,septicemia) Severe infection Malaria andARI Malnutrition n11 43% 0.07%(1) 5% (7) 4%(6) 0.07% (1) 7% 9% 3% (4) (n=141) (10) 7% (12) 9% (meningitis,septicemia) Severe infection Tetanus Measles withorwithoutcomplications andARI Malaria Diarrhea Malaria anddysenteryordiarrhea Malnutrition ARI anddysenteryordiarrhea Dysentery stools (40%), andchestin-drawing(40%). blood instools(both43%),frequent/watery (82%), palepalms(57%),fast breathingand interviewers, mostcommonly mentionedfever time ofdeath,caretakers,when promptedby For childrenolderthan1month atthe 31% (29) 13% (13) 38% (54) 12% (11) (10) (13) contractions, stopped beingabletofeed) or with theseveresymptoms (convulsions, oftheirchild’sbegan thedescription illness spontaneously inafewcases. age respectively, but itwas onlymentioned neonates andchildrenolderthan1monthof in responsetoprompts41%and43%of that ledtothedeathofchildwasidentified 1 month). Fast theillness breathingduring neonates and82%ofthechildrenolderthan prompted by theinterviewer (in43%ofthe mentioned frequentlywhencaretakers were spontaneously mentionedsymptoms, itwas was notoneofthe10mostcommon spontaneously.For example, althoughfever interviewers’ promptsandthosementioned symptoms mentionedinresponseto ** Qualitycareisdefinedas“average”orbetter,assessedbytheexpertpanel. health posts,hospitalsandprivateclinics. Note: Informalhealthprovidersincludetraditionalhealersandfamilyelders,formalservicespubliccen Figure 4.6MandianaPathwaytoSurvival

In theirnarratives,thecaretakers often differencesThere were between important Outside the home Inside the home Health 330 children make referral to Illness Providers hospital seeks outsidecare 4% (238 children) Caretaker 72% 88% recognize dangersigns 59% (196children) Caretakers comply recommendations (290 children) (126 children) with treatment recognizes Family illness 38% Informal andformal children (88%) hadoneormoredangersigns common andlesssevere, suchasfever. previous symptomsthatare probablymore a severesymptom(stiffneck) whileomitting illness, definingtheonsetas thepresenceof example herchild’s ofhow amotherdescribed seek carebecauseofthesesigns. recognize thesesignsassevereanddidnot neonates, ordiarrhea,theydidnotseemto danger signslikefastbreathing,feverinthe severely ill.Eventhoughcaretakersnoticed actions occurredwhenthechildwasalready were relatedtoanactiontaken,andthese narratives, thefirstsymptomsmentioned common andlesssevere(fever).Inmost skipping othersymptomsthatmightbemore symptoms thattheyconsideredtobesevere, Informal only Formal only According totherespondents, most The narrative onthenext pageisan 17% 32% 23% Caretaker provides 52% (170children) (112 children) home care 34% Provider gives (92 children) quality care Survival 28%** 0% ters, 21 RESULTS 22 RESULTS symptom, eventhoughmostofthechildren mentioned firstwasrecordedastheprimary umbilicus, orbeing “very thin.” fontanel, skinpustules,bleeding,red to feedorbreastfeed,stiffneck,sunken convulsions, contractionsofthebody, inability chest in-drawing,fastordifficultbreathing, include bloodinthestool,bulgingfontanel, health center/postorhospital.Dangersigns to seekingcareatahealthprovider, ideallya upon recognitionbythecaretakershouldlead signs aredefinedasthosesymptomsthat during theillnessthatledtodeath.Danger Figure 4.7Type ofHomeTreatment Given(n=170) The illness of Djamila started with stiff neck. stiff with started Djamila of illness The The child could not eat. My father-in-law My eat. not could child The gave me a powder made from a root for root a from made powder a me gave mixing with Karite butter and using it as an as it using and butter Karite with mixing For theanalysis,dangersign ointment on the neck of the child. My mother- My child. the of neck the on ointment in-law gave me some leaves to boil and boil to leaves some me gave in-law wash the child with the concoction. These concoction. the with child the wash xenlTraditional Medicine External products led to some improvement during improvement some to led products the next two days, but then there was a was there then but days, two next the relapse and respiratory problems made the made problems respiratory and relapse illness worse . . . . . worse illness rlTraditional Medicine Oral Aspirin/Paracetamol Other Medicine Pray/Massage Malaria Drug Malaria Antibiotics ORS 01 02 30 25 20 15 10 5 0 —Mother 4 4 5 8 remain inthehomeforfirst7daysoflife. practices thatrequirethemotherandchildto duetocultural neonates was alsopartly a healthprovider. This low care-seekingfor probable pooroutcome,anddifficultaccessto probably becauseoftheiracutecondition, taken lessfrequentlytoahealthprovider, problems duringthefirstdaysoflifewere those were noolderthanaday. with Newborns days oldatthetimeofdeath,andone-half caretakers didnotseekcarewerelessthan8 (42%) ofthechildrenwithdangersignswhose not take any actionatall. Alargeproportion not seekinganyoutsidecare,while35%did displayed oneormoredangersignsreported percent ofthecaretakerswhosechildren had morethanonesymptom. Twenty-five that ahealthproviderdidnotseethechildat children olderthan1monthofagereported Twenty-five percent of the caretakers whose caretakers the of percent Twenty-five children displayed one or more danger signs danger more or one displayed children reported not seeking any outside care, while care, outside any seeking not reported 35% did not take any action at all. at action any take not did 35% Thirty-six percentofthecaretakers of Thirty-six Percentage 16 16 21 26 children asthe firstresponsetotheillness the mostcommonhometreatment given to the home. most frequenttreatmentgiven tochildrenin and drug, malaria “other medicine”—was the ORS (oral rehydration salts),antibiotics, medicine”—aspirin/paracetamol, “Modern unspecified herbalinfusionstothesick child. giving (26%) ofthecaretakers reported specific diseaseorsymptom. Eighty-seven toproduceaconcoctionforbarks treatinga Caretakers oftenmixed herbs, roots, and accompanied by therecitalofprayers. or givingthechildanherbalbath,sometimes and/orrootsonthebodywith massage barks, frequently includedputtingsomeherbs, response tothechild’s illness. caretakers providedhomecareastheirfirst outside care.Fifty-twopercentofthe child athomebeforethecaretakerseeksany any kindofmedicineoractiongiventothe Home treatment,asshowninFigure4.7,is Home Treatment most otherdangersigns. at atraditionalproviderwasmorecommonfor respiratory problems(7cases).Seekingcare was convulsions(16cases),followedby to seekingcarefromamodernhealthprovider hospital). The dangersignthatmostoftenled a modernprovider(healthcenter/postor traditional provider, and14%soughthelpfrom recognizing thedangersign;28%consulteda after percent soughtoutsidecareshortly they recognized thedangersign(s). Forty-two that they after provided homecareshortly the child'sillness. 88% ofthesesignsduringthefirst2days recognizing reported each).caretakers The and inabilitytofeedorbloodinthestool(6% convulsions (27%),verylowweight(12%), breathing orchestin-drawing)for42%, include respiratorysymptoms(difficult/fast danger signsthecaretakersmentioned all. Inthisagegroupthemostcommon Medicine for was thetreatmentofmalaria “External traditionalmedicine”most percentofcaretakers said Thirty-three diagnosed asbeingcausedbyARI. panel time ofdeath,whichtheexpert caretakers. The childwas 1montholdatthe describes theillnessandactionstakenbyhis during theillnessthatledtohisdeath child whowasnottakentoanyhealthprovider other unspecifiedtabletsorsyrup. modern medicineincludedsulfaguanidineand and antipyreticsconstituted4%.Other only 5%ofallmodernmedicineadministered, mebendazole, andampicillin.ORSconstituted mainly cotrimoxazole,metronidazole, treatment wereantibioticsandanti-parasitics, medicines giventochildrenduringhome practice. Sixteenpercentofthemodern with antimalarialmedicationsisacommon subprefecture ofMandiana,self-medication high prevalenceofmalariainthe those childrenwhohadfever. Becauseofthe subsequently diedofmalaria,butfrequentlyto (21%), notonlytothosechildrenwho records, and the healthcardskeptby verbal autopsyquestionnaires, themedical obtained fromfoursources: thesocialand Information oncare-seeking behaviorwas Care-Seeking Behavior His belly was swollen the day it happened, it day the swollen was belly His we didn’t know what to do and his father his and do to what know didn’t we went to pick up some leaves that we boiled we that leaves some up pick to went and gave him to drink, his belly came down. came belly his drink, to him gave and In thefollowingnarrative,motherofa The other day his belly was still swollen and swollen still was belly his day other The his father went for more leaves that we that leaves more for went father his cooked and gave to the child and his belly his and child the to gave and cooked came down a little that day. We sat down the down sat We day. that little a down came whole day and nobody felt comfortable. We comfortable. felt nobody and day whole gave him infusion of leaves to drink. After he After drink. to leaves of infusion him gave drank this solution he was not able to “hold to able not was he solution this drank himself,” his condition was not normal. At normal. not was condition his himself,” dawn I took the child and wanted to wash to wanted and child the took I dawn him. He was unconscious but I didn’t notice didn’t I but unconscious was He him. it. I poured the leaves solution on him. My him. on solution leaves the poured I it. sister-in-law came to take the child to her to child the take to came sister-in-law house while his father went to the house of house the to went father his while house somebody for medicines to give to the child. the to give to medicines for somebody Before he returned, the child died. child the returned, he Before — Mother — 23 RESULTS 24 RESULTS records showthatthehealthtechnician( 27% arefromahealthpost. The medical records, 64%arefromahealthcenter, and study. Ofthe59records, 9%arehospital medical recordsof59childrenincludedinthis ofthestudy,period thestudyteamobtained social autopsyresults.Overtheone-year This informationcomplementstheverbaland information forlessthan20%ofthechildren. obtain medicalrecordsandhealthcard 330 caretakers,theresearcherswereableto autopsy questionnaireswereadministeredto caretakers. While theverbal andsocial 9% itcouldnotbedetermined.For8%,there death but episodeofillness, andfor toaprior record isrelatednottotheillnessthatled the cases, onthemedical theinformation for theillnessthatledtodeath. For 15%of ofthecare-seeking consultations were part reviewed, only76%oftherecorded posts. the healthprovidersincentersand health agentand health facilitywithaphysician,whilethe the physician (8%). The hospital istheonly (75%), followedbythehealthagent(17%)and technique de santé de technique Medical Records(n=59) Deaths ofChildren Under 5with Figure 4.8DistributionofAll 10 20 30 40 50 60 70 0 Of themedicalrecordsthatwere 2 2 Less than 1 month 15 11 Male Female months agent technique de santé de technique agent 1–11 ) sawmostofthechildren 17 12 months 12–59 34 25 Total agent are related consultations withahealthworker. The had oneconsultation,and 15% hadtwo their lastepisodeofillness. Ofthese, 77% had atleastoneconsultation recordedduring the 55childrenwithhealth cards, 35(64%) consultations. indicatethat,of These criteria death, thedateofanddates respondent, theageofchildattime the duration oftheillnessmentionedby the fromtheinformation about was determined illness thatledtothedeathofchild. This worker the recordedonthehealthcardduring decided tousedatafromthevisitsahealth one consultationdaterecorded. consultation dates, and20cardshave only dates arerecorded,while25cardshavetwo 10 healthcards,threedifferentconsultation diagnosis, andtheprescribedtreatment.On bythe signsobserved thehealthworker, the moment, caretaker toseekcareatacertain symptom thatmotivatedthemotheror illness couldbeobtained,includingthemain sought care, general information aboutthe had healthcardsavailable, andfor thosewho of thedeceasedchild. Fifty-five respondents asked allcaretakers toshow thehealthcard found inthisagegroup. ofmedicalrecords explain thelowproportion birth. This care-seekingbehavior might after sought care)orthedeathoccursshortly asphyxia (where only9% related suchasbirth provider, especiallyiftheillnessisbirth- neonates aretakenlessfrequentlytoahealth for onlyfourneonates.Itappearsthat or older(29%).Medicalrecordsareavailable neonatal period(25%)andchildren12months distribution betweenchildreninthepost- older than1month,withanalmostequal available weremale,andmostofthem children forwhommedicalrecordsare illness thattheconsultationtookplace. death ortotheexact the momentduring information isrelatedtotheillnessthatled makes itimpossibletodetermineifthe is nodateofconsultationrecorded,which To analyze itwas thisinformation, theinterview,During thesurvey team As showninFigure4.8,58%ofthe panel diagnosedascausedbytetanus. old atthetimeofdeath,whichexpert led tothechild’s death. The childwas 15days formal healthproviderduringtheillnessthat described howherchildwasnottakentoa statistically significant. the female children,thisdifference isnot taken for outsidecarecomparedto31%of Although 41%ofthemalechildrenwere for thefirstactiontakenbycaretakers. difference incare-seekingbehaviorisfound healthprovider.to aformal Nogender provider,an informal and40%ofthesegoing outside thehome,with55%ofthesegoingto two percentofthecaretakerssoughtcare This heldtrueacrossalldiagnoses.Seventy- provider duringtheillnessthatledtodeath. that thechildwasnottakentoanyhealth providing homecare,and28%state report illness wasrecognized.Eighteenpercent caretakers tooknoactionatallafterthe of the330childreninstudy, the were olderthan12months. death, threewerepost-neonates,andfour child waslessthan7daysoldatthetimeof the illnessthatledtochild’s death. One visits toahealthworkerthatwererelated health cardanalysisfocusesonlyonthose Lamine’s illness started with the warming up warming the with started illness Lamine’s of her body and crying. I bought quinine as quinine bought I crying. and body her of pills to give to her but there was no was there but her to give to pills improvement. We left it this way and her belly her and way this it left We improvement. In thefollowingnarrative,amother According tothesocialautopsyfor10% started to swell, I gave her mint alcohol that I that alcohol mint her gave I swell, to started applied afterwards on her body without any without body her on afterwards applied improvement. After that the contractions, the that After improvement. closed hands and she frequently refused frequently she and hands closed breastfeeding. We went to see a traditional a see to went We breastfeeding. healer who gave us leaves and told us to us told and leaves us gave who healer boil them to wash the child, but I didn’t I but child, the wash to them boil respect him because it is said that the leaves the that said is it because him respect can worsen an infection. It was at this at was It infection. an worsen can moment when the child found the death. the found child the when moment — Mother — illness lasting5daysorless. all childrennottaken toany provider hadan factor;illness was anotherimportant 83%of between 14%and25%. The durationofthe did notshowmajordifferences, varying care. Intheotheragegroups, thisproportion were less than 1day olddidnotseekoutside newborns; caretakers of88%thosewho care. This percentagewasespeciallyhighfor seekingnooutside than 8days oldreported The caretakers of65%theneonatesless months for thosewhodidseekoutsidecare. months, comparedtoanaverage ageof11.2 at allaftertheillnesswasrecognized was4.9 34 childrenwhosecaretakers tooknoaction duration oftheillness. The average ageofthe time oftheillnessleadingtodeathand community were theageofchildat caretakers soughtcareinoroutsidethe other factors whether thatdetermined seeking rates. committees, contributedtohighercare- population bythetrainedvillagehealth training, aswellthemobilizationof upgrading ofthehealthcentersinmaterialand distance away(morethan15km),butthe Balandougouba healthcentersarealsoalong that soughtcareattheSansandoand 35 kmaway. However, several ofthevillages forced patientstopurchasemedicineatasite lack ofmedicationinthehealthcenter, which post; duetoa inNyantanina, itwaspartially distance (15km)fromthevillagetohealth Nyantanina duetothelong was partially rate ofcare-seekinginFaralako and from thehealthpostorcenter. The low directly correlatedtothedistanceofavillage (37%). Lowlevelsofcare-seekingwerenot in Sansando(38%)andBalandougouba Faralako (14%)andNyantanina (9%)andbest from 9%to38%.Care-seekingwaspoorestin provider inthevarioussubprefecturesranges that theydidnottaketheirchildtoanyhealth ofcaretakers whoreported The proportion Age andGeographicalConsiderations In additiontogeographicaldifferences, 25 RESULTS 26 RESULTS reported takingthechildtoany health reported asphyxiacaretakers ofneonateswithbirth As Table 4.5shows, only9%ofthe for whichcarewasleastlikelytobesought. first daysoflife,wastheneonatalcondition the orduring afterbirth only newborns right asphyxia, anacuteillnessaffectingBirth Care-Seeking PatternsbyDisease oa 4(0)5 1% 2(8)1. 2 . 1.1 0.6 2.3 0.6 3.2 72% 1.0 0.8 1.0 46% 16.7 1.2 92(28%) 2.1 4.7 1.7 58(18%) 29% 10.5 34(10%) 1.3 6 (54%) 21 5(45%) 62% 1.7 50% 1.4 1 (9%) 5(71%) 77% (28.5%) 2 4 17 Total 3(42%) 2.6 4.4 (n=11) Other 10(38%) 3 (50%) 1.3 4 (15.3%) possible (n=7) 3 (50%) 8(23%) 6 (23%) No diagnosis 0.1 (14.7%) 5 31.5 infection) (n=26) 91% 3(8.8%) 3.1 – neonatal septicemia, – 1.2 0 (meningitis, 13 Severe infection 1.2 86% 1(9%) (n=34) 1.8 1.7 – Neonatal tetanus 1.3 53.7 1 (9%) 9% 3.4 (n=6) 3(14%) complications 2.8 without 1(4.7%) 78% 2.3 – – Measles with/ 1 2(9.5%) 76% (n=21) Malnutrition sought 21(91%) 5.6 diarrhea(n=11) 93% 7(30%) 83% 27.5 or dysentery 18 (22%) care 13 (15.6%) 14(61%) Malaria and 6 (24%) 15.7 5 (6%) (n=11) 12 6 (24%) and ARI Malaria 1(7%) care 10(17%) (n=83) Malaria 10(17%) 1 (7%) – (n=23) (days) asphyxia Birth sought – (n=25) dysentery – provided Diarrhea/ caretaker ordiarrhea(n=14) ARI anddysentery ARI (n=59) Disease Expert Panel) Table 4.5Care-seeking BehaviorbyCauseofDeath(asDefinedthe oato nyhm usd uaintknfrseigof times seeking takenfor duration outside Only home No action ae ycr aeo lns usd usd care was outside outside of illness care care taken by oAeaePretg lns n number illnessand Percentage Average No provider were fever, cough,convulsions, and common reasonsforseekingcareatahealth (76%). infections (62%),anddiarrhea/dysentery or withoutcomplications(50%),severe ofcare-seeking aremeasleswith proportion provider. Otherdiagnoseswithalow Medical recordsshowthatthemost eonzn Average recognizing between Average number of days examination was recorded. information ontheclinicalfindings during health worker. Unfortunately, nodetailed reason forconsultationnor observedbythe unconsciousness wereneither recordedasa inability tobreastfeedordrink, stiffneck,and symptoms. Signsofsevereillnesssuchas diarrhea (22%)werethemostcommon problems (37%),convulsions (26%),and on theavailable data,fever (78%),respiratory the healthcardby thehealthworker. Based recorded on health worker were onlypartially byconsultation andthesignsobserved the vomiting, andanorexia. The reasonfor diarrhea, followedbyrespiratoryproblems, reasons forconsultationwerefeverand and onehadaproblemwiththeumbilicus. able tobreastfeed, twowere notable tocry, neonate wasunconscious,threewerenot bydescribed thecaretaker (Table 4.6); one health workerweredifferentfromthose the fourneonates,signsobservedby (25%). Accordingtothemedicalrecordsfor of thehands(19%)andconjunctiva in 44%ofthecasesbyexaminingpalms the cases,healthprovidernotedanemia was thecauseforconsultationinonly5%of diarrhea. Eventhoughlowweightorpallor oiig5812 5 29 42 20 93 1 44 3 17 25 12 55 8 5 26 24 46 29 93 5 5 3 14 27 17 55 3 Crepitant sound(auscultation) Difficult breathing Low weight orpallor (anemia) Vomiting Diarrhea Convulsions Cough Fever and SymptomsMostFrequentlyObservedbyHealthProvider(n=59) Table 4.6MostCommonReasonsforTaking ChildtoHealthProvider, andSigns The healthcardsindicatethatthemain in rsmtm o o % No. % No. Signs orsymptoms o ekn aebythehealthprovider for seekingcare ie srao most frequently observed Given asreason (median: 4,mode: 3,SD:17.91).Because of days aftertheillnesswas recognized consultation tookplacean averageof11 care-seeking fortheillness ledtodeath,the were ofthe taken toahealthprovider aspart (median: 5,mode:3).Forthe 45childrenwho 17 days,witharangefrom1to150days records, theaveragedurationofillnesswas questionnaire. Accordingtothemedical behavior analysisofthesocialautopsy health cardsconfirmsthecare-seeking days. care forthefirsttime,onaverage,after2.3 seeking conditions, thecaretakers reported similar acrossalldiagnoses.For outside careduringagivenillnesswas seeking number oftimescaretakers reported durations.tetanus, had short andmalaria The asphyxia, neonatal infection,birth neonatal illness, 26and29days respectively, while dysentery hadalongaveragedurationof such asmalnutrition.Bothdiarrheaand conditions andthosewithchronicillnesses between thosechildrenwithmoreacute in thedurationofillnesswereevident duration ofillnesswas 16.7days. Variations thattheaverageThe caretakers reported Delay inCare-Seeking The analysisofmedicalrecordsand Signs andsymptoms 27 RESULTS 28 RESULTS consultation. died anaverageof1.5daysafterthis for theneonateswas8days,andinfants health provider. The meanduration ofillness of survivalbythetimetheyweretakento were alreadyseverelyillwithlittleprobability average of7daysillness.Allneonates sought carewitha days, range: 1–180days). The caretakers illness was18days(median:8days,mode3 the healthcards,averagedurationof (median: 4,mode: 1). Similarly, accordingto to 83days,withanaverageof32days consultation thatthechilddiedvariedfrom0 illnesses, thenumberofdaysafter the greatdifferencesbetweendurationof for 57%ofall ofthecare-seekingover most frequentlyvisitedprovider, accounting actions.fourth The traditionalhealer was the were amorecommonchoice forthethirdand already severely ill; specifically, hospitals facilities werevisitedwhen thechildwas during theillnessofchild.Publichealth also frequentlythefirstproviderconsulted most commonoverallproviderconsultedbut from modernproviders. seekingcare caretakers moreoftenreported diarrhea/dysentery (61%)andmeasles(80%), (59%).(68%), andmalnutrition Conversely, for providers forneonataltetanus(78%),ARI seekingcare fromtraditional reported For example,themajorityofcaretakers provider wasvisitedvarieswiththedisease. number oftimesatraditionalormodern a traditional provider. The distribution ofthe seekingcarefrom of thecaretakers reported According tothesocialautopsyresults, 55% Source ofCare The traditional healer was not only the most the only not was healer traditional The common overall provider consulted but also but consulted provider overall common frequently the first provider consulted during consulted provider first the frequently the illness of the child. the of illness the The traditionalhealerwasnotonlythe formal provider afteran self-medication. care oradvicebutaplaceofpurchasefor that thedrugsellerisnotasourceofmedical represent theperceptionofcommunity to92children.number rises This may questionnaire (open-endedquestion),this provider, butinthesocialautopsy children werenotbroughtforcaretoany question), respondentsindicatedthatonly77 verbal autopsyquestionnaire(closed-ended were broughtfor caretoany provider. Inthe differences inthenumberofchildrenwho during theillness,buttherewerealso questions inthetypeofprovidersconsulted differences betweentheresponsestotwo of modernmedicine.Notonlywerethere although theydidmentiongivingsometype ofany actiontaken theillness during part did notmentionconsultingdrugsellersas (through anopen-endedquestion),caretakers when askedtodescribecare-seeking seller,at adrug 103saidthey had. However, questionnaire whethertheyhadsoughtcare closed-ended questionintheverbalautopsy to 50%duringactionsfiveandseven. second actionto42%ofallcare-seekingand the healthcentersincreasedduring course oftheillness.Seekingassistancefrom medicine were malaria(27%ofthese commonly believeduntreatable bymodern medicine.by modern The illnessesmost thought thattheillnesscould notbecured the severityofillness, and13%also caretakers saidthattheydidnotrecognize medication. percentofthe Thirteen consultation, andinsomecases money topayfor transportation, money (26%);caretakersdidnothavethe frequently mentionedreasonwaslackof provider (healthagentorhospital). caretakers fornotvisitingapublichealth their death. There aremany reasonscitedby workers sawonly40%ofthechildrenpriorto According tothecaretakers,formal health Reasons forNotSeekingCare When caretakerswereaskedasa As shown in Table 4.7,the most considered tohaveaspiritualoriginand include convulsions,whicharecommonly of severemalariaandneonataltetanus and diarrheaordysentery(15%).Symptoms cases), neonataltetanus(24%),ARI(16%), hat gn/optl2 . 01845 (4%) 6 148(13%) 1.8 6 (4%) 47 3 20 2 69 283(26%) 36 2.5 (8%) 84 14 26 7 (4%) 48 5 157 25 2 2 79 56 12 (13%) 148 20 21 7 2.5 126 2.5 74 moment(atnight) 28 No healthservicewasavailableatthat 28 7 healthagent/hospital The childwastoosmalltobetakenthe It istoofar, Iwas atthefield We firstwantedtotrytraditionalmedicine 74 An injectionwouldriskchild'slife medicine The illnesscouldn'tbetreatedwithmodern Thought thattheillnesswasnotserious No money Reasons mentionedspontaneously te 176 6 66 7 4 40 (4%) 81 3 2.5 (3%) 38 2 25 29 21 1 1.5 15 17 Other healthagent The childhadalreadybeenseen bya My husbandwasnotathome Poor transportation Center orHospital(n=1103) Table 4.7Ten MostFrequently MentionedReasonsforNotGoingtoaHealthPost/ child the while started child the of illness The was lying down. He was sleeping when sleeping was He down. lying was suddenly he cried out loud. I took him and sat and him took I loud. out cried he suddenly him on my feet. His arms were contracted as contracted were arms His feet. my on him well as his body and liquid came out of his of out came liquid and body his as well mouth. I sent the child to the health center health the to child the sent I mouth. without having boiled the leaves, and the and leaves, the boiled having without health agent gave the child 6 injections 6 child the gave agent health without any improvement . . . Every time the time Every . . . improvement any without health agent came to look at the child he child the at look to came agent health would give him an injection, made the child the made injection, an him give would lie down and nobody could touch him. At him. touch could nobody and down lie night I told him to stop with the injections the with stop to him told I night because they didn't seem appropriate to me, to appropriate seem didn't they because and that is why we returned to our house, our to returned we why is that and laid him down and suddenly he died. he suddenly and down him laid — Mother — Health agent/center #(%) % # % # facility theyusuallytooktheirchildtoforany Caretakers wereaskedwhattypeofhealth available atthatmoment[atnight].” 4% alsostated,“Nohealthservicewas respondents saidthat “It [was] toofar,” and hours wasalsoaconcern.Fourpercentofthe months oldatthetimeofdeath. left about achilddiagnosedwithmalaria,30 injections canbeseeninthe narrativeto the injections. Anexampleofthefear caretakers believewillworseniftreatedwith conditionsthat that therearecertain taken tothehealthagent/hospital.Itseems caretakers thatthechildwastoosmalltobe may alsoaccountforthebeliefby4%of prescribed bytheformalhealthservices, injections, acommontypeoftreatment fear ofinjectionsareincluded.Fear to anyhealthagentorhospitalbecauseof medicine increasesifthe8%whodidnotgo illness couldnotbetreatedbymodern group ofcaretakerswhobelievedthatthe thus nottreatable medicine. by modern The Accessibility intermsofdistanceand optlTotal Hospital .542 0.05 .433 0.04 147 (13%) (3%) (4%) 29 RESULTS 30 RESULTS prefecture. As expected,theaveragetime median timespentiscalculated fortheentire subprefecture) was low, very theaverage and taken tothehealthpost(health centerineach Because thenumberoftimes achildwas there by theirusualmeansoftransportation. illness oreventandhowlongittooktoget Hospital rvt rvdrGv oenmdcn rMdr eiieo neto 78% injection or medicine Modern Gavemodernmedicineor provider Private et etrEaie h hl 6 Referredthechildtoanother 26% child the Examined Gavethechild center heath Heath agent or h ilg rn 75% drink bathethechildand/orgive itto 40% to medicine Herbs/traditional leaves) the village Gave thechildherbs(roots, barks, or men/women of Traditionalhealer Table 4.8Providers’ ActionsandPrescriptions rvdrPoie’ cin Provider’s Prescriptions Provider’s Actions Provider rijcin6%Mdr eiie42% Modernmedicine 8% 60% 10% 10% 50% Givethechildmorefluids 20% child the Hospitalized Cured theumbilicus Examined thechild products unspecified Gave or injection Gave thechildmodernmedicine neto 89% Advisedcontinuedfeedingfor 11% child the Examined injection te %A 2% Tr 1% 3% follow-up for child the Cited 23% Other Gave thechildORS 1% Gave thechildtraditionalmedicine Gave thechildaninjection rdcs6 rvdr4% 1% 3% 4% 2% provider 6% Advisedcontinued feeding for 5% 28% Other child the Referred thechildtoanother 12% Other or injection 16% 5% Gave medicine thechildmodern traditional medicine thechild with Bathed orrubbed Citedthechild for follow-up products medicine Modern Gaveunspecified child the Examined thechild the child Koranicblessing versesand/or Massaged thechildwhilereciting (n=211 actions) (n=220 recommendations) (n=220 (n=211 actions) (n=313 actions) (n=212 recommendations) (n=212 (n=313 actions) (n=10 actions) (n=12 recommendations) (n=12 (n=10 actions) (n=9 actions) (n=9 recommendations) (n=9 (n=9 actions) oenmdcn 47% modern medicine center. encountered inaccessinga healthpostor provides anexampleofthe difficulties almost onehour. The following narrative health center(2.45hours)—a differenceof was lessthanthetimerequired togothe spent totravelahealthpost(1.46hours) h hl 11% 11% the child Cited thechildforfollow-up te 7% 2% Other the child netos2% 3% Injections provider oenmdcn 81% Modern medicine dvised continuedfeedingfor dtoa eiie2% aditional medicine health agentwas consulted.Insomecases, as acommontreatmentwhen anyformal interviews, thecaretakermentioned injections theinterview.mentioned during Inmost only whatthecaretakerspontaneously becausetherecorded dataincludes reported of injectionswaspossiblyevenhigherthan medication.means ofadministering The rate injection. Injectionsseemtobeacommon and in23%ofthecasestheygavean prescribed sometypeofmodernmedicine, healer. taken morethanonetimetothetraditional common, andthatthechildwasnormally giving thetraditionalmedicine,were continued theblessing,recitingverses,and up visitstocompletethetreatment,which the caretakers’answers,itseemsthatfollow- massage ismentioned88times(28%). From (51%). RecitingKoranic verses the during bathing, rubbing,ormassagingthechild then giventothechilddrinkorusedfor roots, herbs,orleavesboiledinwaterand some typeoftraditionalmedicine,usually traditional healerinvolvedgivingthechild treatments givenduringconsultationwiththe autopsy questionnaire.Mostofthe to thecaretakers’responsessocial both informalandformalprovidersaccording Table theactionstaken 4.8summarizes by Quality ofCare The illness of the child started with the white the with started child the of illness The infection (pallor/anemia). I gave him pills but pills him gave I (pallor/anemia). infection they had no effect. I washed him in the water the in him washed I effect. no had they of cooked leaves without any improvement. any without leaves cooked of In mostcases,thehealthworkers The next day I decided to go to the village the to go to decided I day next The because we live in a small settlement but a but settlement small a in live we because storm flooded everything and the stream the and everything flooded storm overflowed. I waited for the level of the water the of level the for waited I overflowed. to drop because this usually doesn't take too take doesn't usually this because drop to long. Right afterwards I took the path to the to path the took I afterwards Right long. village. That day the level of the water came water the of level the day That village. up to my waist . . . . . waist my to up — Mother — based onthemedicalrecords(seep.33). assessed andscoredthequalityofcare kept by thecaretakers. Apanelofexperts the healthcardsofdeceasedchildren deceased childreninthehealthfacilitiesand analyzing themedicalrecordsof providers wasevaluatedinthisstudyby questionnaire, thequalityofcareformal during theillnessofchild). consulted anyhealthcenter/postorhospital the caretakers’reasonfornothaving (fear ofinjectionswasmentioned84timesas cause harmandworsenthechild'scondition but inothercasestheywereconsideredto injections wereseenastherightmedication, given tosixchildren whowerepale. only 34ofthem. Treatments for were malaria fever), eventhoughadiagnosis wasmadefor 49 children(83%ofthosepresenting with examined, treatmentformalaria wasgivento medication prescribedtoalmosteverychild paracetamol. Inadditiontotheantipyretic them receivingacetylsalicylicacidor prescribed to93%ofthechildren,most rash orbleeding. of therecordsdocumentedgeneralizedskin records for2childrennotedastiffneck.None thepresenceofconvulsions, andthe reported chloroquine. the presenceoffeveroranemia,with treat suspectedcasesofmalaria,basedon ofHealth’sMinistry policytopresumptively performed. This isconsistentwiththe although only8%hadabloodsmear diagnosis ofrecordin58%thecases illnesses couldcausefever, was malaria the which 51%wereelevated.Eventhoughmany documented thechild’s rectaltemperature, of even thoughonly56%ofthemedicalrecords reflected thattheprovidersalsonotedfever Interestingly, 93%ofthemedicalrecords the medicalrecordswasfever(93%). The mostcommonpresentingcomplaintin Fever Management In additiontothesocialautopsy The symptomatictreatmentoffeverwas The medicalrecordsof12children 31 RESULTS 32 RESULTS of diarrhea. data inthemedicalrecord),suchascases without acleardiagnosis(accordingtothe prescribed for28children,insomecases had chestin-drawing.Oralantibioticswere the datawhetherremaining56children in-drawing inthreechildren.Itisnotclearfrom for onlyonechildandthepresenceofchest The medicalrecordsstatetherespiratoryrate auscultation; 17childrenhadcrepitantsounds. established adiagnosisofpneumoniaby records reflectthattheproviderslargely these childrenalsohadanotherillness. The were diagnosedwithpneumonia,and20of complaint inonly2or3children. drawing, wereidentifiedasthepresenting breathing, difficultandchestin- respiratory dangersigns,suchasfast a presentingcomplaintcough.Other are relatedtotheassessmentofchildrenwith Twenty-seven (46%)ofthe medicalrecords Respiratory Management children were diagnosed withdiarrhea, days, withamedianof10days. duration oftheillnessthatled todeathwas23 months atthetimeofdeath. Onaverage,the to 6monthsold,andninewereolderthan with diarrhea,nonewereneonates,two1 for 11ofthe14children.Ofthesechildren related totheillnessepisodethatleddeath of thechildren. The diarrheaepisodewas of bloodinthestoolwasassessedonly25 one case. The recordsreflect thatthepresence number ofstoolsperdaywererecordedinonly 7 children. The duration ofthediarrheaand dehydration wasassessedornotfortheother the recordsdonotdescribewhether dehydrated and22hadsomedehydration,but half ofthechildrenwithdiarrheawereseverely records. Accordingtothemedicalrecords,one- was notproperlyrecordedinthemedical children. Acompleteevaluationofthediarrhea the mainpresentingcomplaintfor14(24%) The medicalrecordsstatethatdiarrheawas Diarrhea Management The recordsstatethat21children(36%) The recordsstatethatallbut threeofthe diagnosis ofmalnutrition. age. recorda Onlyfive (8%)ofthecharts for the18(31%)childrenwithlow weightfor (19%) childrenwithverylowweightforageor action ortreatmentwasprescribedforthe11 becausenospecific the weightfor agechart does notappearthatthehealthproviderused for the59childrenrecordchild’s weight, it Even though47(80%)ofthemedicalrecords Nutritional Evaluation one diedthreedaysafterconsultation. children diedthedayafterconsultation,and parenteral, ororal antibiotics. Two ofthese back homewithanORSprescription, children indicatethattheseweresent the sameday. The recordsfor theothernine led totheirdeath,2werehospitalizedanddied who wereseenduringtheillnessepisodethat malaria and/orpneumonia.Ofthe11children including thosewithotherdiagnoses,usually did notreceive immunoglobulinduringthe having pneumonia,andgentian violet(1). for tetanus(1)giventoachild diagnosedas mebendazole) for2children, immunoglobulin treatment forparasites(metronidazoleand with pneumoniaandonemeningitis, (2)given toachild (4), thiamin(3),cortisone medicines prescribedwereIV/IMantibiotics (13), andanti-convulsives(11).Other antimalarials (18),ORS(15),iron/folicacid intravenous/intramuscular (IV/IM) antimalarials (49),oralantibiotics(28), medicines wereantipyretics(55),oral was only5days. though theaverage washigh,themedian of illness(mean=17days) was sohigh. Even child. thattheaverage Itissurprising duration related totheillnessthatleddeathof percent oftheclinicalrecords(4559)are beingthemostcommon.malaria Seventy-six documented inthemedicalrecords, with facility, morethanonediagnosisis For mostofthechildrenseenatahealth Diagnosis andPrescribedTreatment The threechildrendiagnosed withtetanus The sevenmostfrequentlyprescribed included thefollowingaspects: and thenestablishedaqualityscore,which provider duringtheillnessthatledtodeath records ofthechildrenseenbyhealth panelanalyzedThe expert the45medical (Analysis oftheMedicalRecords) of CareattheHealthFacilities Expert PanelEvaluationoftheQuality cost, atthehealthfacility. prescribed wereavailableandprovided,at convulsions. received anunspecifiedtreatmentfor consultation, butallofthemwerereferredand Expert Panel(n=45) Figure 4.9ComparisonofDiagnosisGivenbyHealthWorkerand In 79%ofthecases,medications Malaria/Anemia orMNT Malaria/Anemia Malaria/ARI/Diarrhea Malaria/Meningitis Umbilical Infection entlTetanus Neonatal Malaria/Diarrhea Severe Infection ARI/Diarrhea Tuberculosis ARI/Anemia ARI/Malaria Malnutrition Diarrhea Measles Malaria Other ARI 0246810121416 ■ ■ ■ ■ ■ Number ofCases Prescribed treatment. the panel'sdiagnosis. Health worker's diagnosiscomparedwith missing). recorded, butalsoiftherewasinformation (not onlywhatsignsandsymptomswere he/she wasseenbythehealthworker Information aboutthechildcollectedwhen when thehealthworkersawchild. symptoms, andthepointduringillness including itsduration,signs,and Information relatedtothechild'sillness as ageandsex. General informationaboutthechildsuch elhWorker Health PanelExpert 33 RESULTS 34 RESULTS according tothediagnosisofcausedeath. on differencesinqualityofcaregiven care given. There isnotenoughdatatoreport posts, thisisnotreflectedinthequalityof a highereducationallevelthanthoseathealth providers inthehealthcentershave attained of healthposts(20.3%).Although similartothat health centers(18.2%)isvery 29% poorcare. The average quality scorefor provided goodcare, 61%average care,and panel,10%ofthehealthworkers the expert According tothequalityassessmentof 4.10. panel,arerepresentedinFigure the expert canbeseen. and malaria with asignificantpresenceofARI/pneumonia probable causeofdeath. Multiplediagnoses withtheavailabledetermine, data,the to disease, paneltried whiletheexpert worker established oneormorediagnosesof difference mightbebecausethehealth otherwise by thehealthworkers. This or ARIfor anumberofcasesdiagnosed diagnosed thecauseofdeathtobemalaria panel.expert Similarly, panel theexpert thatwere diagnosedbyand malnutrition the recognize casesofmeasles, severe infection, (Figure 4.9). The healthworkers didnot the diagnosesassignedby panel theexpert diagnoses givenbythehealthworkersand used for thequalityassessment. care. AnnexEcontainsthedetailedscale scores attheendtofindoverallqualityof assigned ascorefrom1to3andaddedthe died shortly afterwards. died shortly mainly becausethechildwas severelyilland follow therecommendations, butthiswas (18%) ofthecaretakerssaidtheydidnot recommendations fortreatment.Only42 following196 (82%)reported theproviders’ Of thecaretakerswhosoughtexternalcare, Recommendations Treatment andReferral Quality ofcarescores, asassessedby There isalargevariationbetweenthe panel For theexpert eachcriterion, illness. referred becauseoftheseveritytheir 10% werereferred.Alloftheneonates before admission,10%werehospitalized,and the healthproviderweresenthome,2%died medical records,78%ofthechildrenseenby the medicalrecordsanalysis.Accordingto referrals. isavailable Partial information from the interviewerdidnotspecificallyaskabout unless theywereprompted,andinthiscase, often neglectedtomentionactionstaken questionnaire. Asinmanystudies,caretakers children fromthesocialautopsy to anothercouldnotbedeterminedforall the CareProvidedbyHealthWorker Figure 4.10QualityAssessmentof The numberofreferralsfromoneprovider Average 61% Good 10% Poor 29% The studypopulationispoorer thanthe Study Population Socioeconomic Conditions ofthe theresultsofstudy.interpreting characteristics thathaveimplicationsin whether thissamplehasunique Survey Health indetermining areimportant and comparisons Demographic data drawnmainlyfromthe1999 sampling methodology, aswell astonational who wereselectedbymeansofa30-cluster mothers ofchildrenundertheage2years, Practices, andCoverage(KPC)surveyfor 1997 SC/USprojectbaselineKnowledge, for Mandiana’s generalpopulationfound inthe results ofthisstudywerecomparedtodata the populationofMandianaasawhole, the studygroupissignificantlydifferentfrom populace asawhole. To whether determine sample populationisrepresentativeofthe survival interventionsinGuineaonlyifthe inform decisionmakingforfuturechild The resultsofthisstudycanbeusedto Characteristics Comparison ofSample inGuinea. epidemiology ofchildhoodmortality community-based datatodescribethe data. This may bethefirststudytouse information isavailablefromfacility-based the countryorregion,andwhat death amongchildrenundertheageof5in currently littleinformationaboutthecausesof and healthcare providers thatcontributedtomortality. There is of childreninMandianaandthebehaviorschildren'scaretakers describe boththeproximatediseaseprocessesthatledtodeath basing theanalysisonPathwaytoSurvival.Theobjectivewas S Discussion that contributetothehighchildmortalityratesinMandiana, ave theChildrenundertookthisstudytodeterminefactors (DHS). These levels. ofadultfemaleThe proportion study andismuchlowerthan national than whatwasfoundinthe MandianaKPC population isonly5%. This iseven lower is notpoorerthantheMandianapopulation. is poorerthanthegeneralruralpopulation,it suggests thatalthoughthestudypopulation general populationofMandiana. This the SC/US’s 1997KPCfindingsfor the occupational characteristicsaresimilarto population’s accesstopotable water. The Mandiana, andthishasincreasedthe recent ponds, andotherunprotectedsources.Inthe obtains drinkingwaterfromrivers,streams, rural Guineainwhich43%ofthepopulation unprotected sourcescomparedtomostof population obtainsdrinkingwaterfrom potable water. Only9%ofthestudy to thesepoorerconditionsisaccess national ruralaverageof76%.Anexception floors(89%)isalsohigherthanthe earthen 1997a). ofhouseswith The proportion sleeping inasingleroom(SavetheChildren households havingthreeormorepeople people perroom,withonly37%of higher thannational(rural)averageof2.6 house withthreeormorepeople. This is the studypopulationsharesaone-bedroom are livinginmorecrowdedconditions;66%of population indicatethatthe housing characteristicsofthestudy populationinGuinea.general rural The The literacylevelofwomen inthestudy years, manywellshavebeendrilledin study study population 5 35 DISCUSSION 36 DISCUSSION population inMandiana. likely notdifferentfromthatofthegeneral literacy levelofthestudypopulationis literate inArabic,whichwouldmeanthatthe percentage ofwomenwhoareactually included inthisstudy, sotheremay bea Koranic school. This responsewasnot the womeninterviewedhadattendeda studies (1997KPC)havefoundthat8.9%of population inGuineaisMuslim,other Children 1997a).Because82%ofthe dropping to10%inMandiana(Savethe literacy inGuineais20%(Census1992), number ofsurvivingchildren. children bornbutapproximatelythesame study populationhasahighernumberof slightly lower thanthenationalaverage. The average numbersurvivingis2.46,only is 33%higherthanthenationalaverage. The towomen inthestudygroup is4.55.born This (DHS 1999). The average number ofchildren and theaveragenumberwhosurviveis2.63 ever borntoallwomenis3.42(DHS1999), Nationally, theaverage number ofchildren Maternal ObstetricHistory ese 41 71 64 18 18 23 15 54 61 70 29.5 76 45 61 70 Complete coverage 73 Measles DPT 3 76 57 DPT 2 DPT 1 OPV 3 OPV 2 OPV 1 OPV Birth BCG (Children 12–23MonthsOld)byCard Table 5.1ComparisonofVaccination Coverage acns%%%% % % % Vaccines hl otlt CU/O anddistrictdata SC/US/MOH mortality Child uvyKPCStudy survey n3)(=3)1999 data (n=139) (n=33) 6571 28.1 16.5 21.6 25.9 28.8 communications topromotedeliveriesby midwives andhealthworkersaswell program thatincludedtrainingfortraditional SC/US begananextensivesafemotherhood provider. AnotherreasonisthattheMOHand women seekingcarefromatrainedhealth of that would resultinahigherproportion complications withthepregnancyordelivery (neonatal deaths),theremighthavebeen that for29%ofthecasesinthisstudy differences mightbeexplainedbythefact lower than whatwas found inthis study. The 23.9% by TBAs. ismuch This proportion were assistedbyamedicalproviderand according tothe1999DHS, 21.3%ofbirths this studyand51.5%intheKPC. Nationally, attendant(TBA)was 44%in traditional birth nurse. assistedby a ofbirths The proportion fromatrainedphysician, midwife,support or that only9.9%ofthewomenreceived much higherthantheKPCdata,whichfound atdelivery.had trained laborsupport This is by trained midwives. Thus 63%ofwomen by healthworkersand25%oftheseattended home deliveries,with38%oftheseattended In thisstudy, were 84%ofthebirths September (1997provincial provincial HIS) Guinea official from MOH statistics ages 1to6months. This dataiscomparable only 4%exclusivelybreastfed thechildduring the childneverexclusively breastfed,and the caretakersinthisstudy respondedthat much lessextensive.Eighty-six percentof the 1992Census),exclusive breastfeeding is compared to93%found intheKPCstudy and the childreninthisstudywere breastfed, practice for mostwomen inGuinea (91%of Even thoughbreastfeeding isacommon Breastfeeding children. contributed tosomeofthedeaths the lackofvaccinationprotectionmayhave minor, but itisprobably significantbecause coverage inthestudychildrenmayappear oftime.the sameperiod The difference in coverage foundinthestudypopulationfor September 1999. This ishigherthanthe vaccination coveragelevelwas64%in thatthecomplete The MOHreported provided totheMOHimmunizationprogram. SC/UShas to theintensive support KPC study(36%). This improvement isdue immunization waslower(22%)thanforthe ofchildrenwithout The proportion 15%; inthestudypopulationitwas45%. study. In1997,thecompletecoverage was population surveyedforthe1997KPC coverage inthestudychildrenthan cautiously. is asmallsamplesoitshouldbeinterpreted included inthedenominator Table 5.1. This children 12monthsorolder(33children)are immunization coverage onlythose reports, To make thestudydatacomparable withother Immunization Wellness Behaviors the deliveriesoccurredunassisted. births, TBAs assistedin29%,and15%of health providersassistedin18%ofthe settings. Intheruralareas,medicalortrained are largedifferencesbetweenruralandurban trained personnel.Inthe1992Census,there There isconsiderablyhighervaccination of children. hadtothemortality contribution malnutrition population indicatestheimportant poorer nutritionalstatusof the study lowweightage and5.1%arevery for age. The DHS datainwhich23.2%are lowweightfor under 3years old. This isalsosimilartothe 15–22% withlow weightfor ageinchildren lowof 5–11%withvery weightfor age and andSeptember1999findsarange January population. Growth data between monitoring growth datafor monitoring thegeneral thantheSC/USandMOH malnutrition study findingsshowmuchhigherlevelsof lowchildren hadvery weightfor age. The was 12to23monthsold;53%ofthese seemed tobemoreaffected by malnutrition adequate weight for age. The agegroup that 31% hadlow weightfor age, and43%had lowchildren, 26%hadvery weightfor age, Mandiana. practices foundinthegeneralpopulation study, but they arelikely similar tothe practices werenotexplored inthemortality offered fruit).Complementaryfeeding and vegetableswerenotusuallygiven(39% eggs ornon-breastmilk. fruits Vitamin-rich giving to thechildren,andonly14%reported givingmeatorfish of thesemothersreported semi-solid foodstotheirchildren.Only35% thatthey gaveof thesechildrenreported 6 to 11monthsold.Only56%ofthemothers supplementary feedingpracticesinchildren above). The 1997KPCsurvey found poor Mandiana (seediscussiononbreastfeeding breastfeeding practicesatthisagein generally poorcomplementaryfeedingand months). This couldbeexplained by the low weightforageintheinfantgroup(0to11 low ofvery weight and to thehighproportion The post-neonatalgroupcontributedthemost Growth Monitoring respectively. 4.4% oftheunder-6-month-oldinfants, found exclusivebreastfeedingin5.2%and with KPCfindingsandnationaldata,which For allagesinthestudypopulation 37 DISCUSSION 38 DISCUSSION *** Includesanemia for1992(7%);source:CIHI1995. ** Includesgastroenteritisfor1986. There canbeseveraldiseasesthat contribute toonedeath,sothetotalforalldiseasesismorethan100%. MOH dataishealthfacility-based. Cambodia. InMandiana,57%ofallchildhood to thatfoundinsimilarstudiesBoliviaand inMandiana,Guinea,iscomparablemortality projectinterventions.survival totheSaveattributed theChildrenchild recent (1999)DHS. This improvement may be approximate nationallevel datafromthemost and UpperGuineamoreclosely compare favorably withtherates for bothrural rates inthestudyarea Age-specific mortality Mortality Rates areData fromthecurrentstudyand1999DHSstudy. Table CausesofChildMortalityinGuinea 5.3Primary te %1%22% 3 13% – 2 5 5 16% 4 16% 10% 9% 5 11% 4 7 9% – 6 6% 1 6 14% 2% 2 6% 5 21% 6% 2 18%** 7% 4 1 25% 3 Other 9% 32% Measles 8% 15% Malnutrition Birth Asphyxia Severe NeonatalInfection Neonatal Tetanus Diarrheal Diseases ARIs Malaria 210.6 177 171 115.8 98 97 60.7 49.6 55.1 47 61.8 48.4 50 Upper Guinearegion Rural Guinea Guinea (national) Mandiana (currentstudy) Table 5.2Age-SpecificChildhoodMortalityinGuinea The agedistributionofchildhood Cause ofChild ralv its livebirt livebirths) Area otlt S/S Estimate (SC/US/ Mortality (per 1,000 (per 1,000 (per 1,000 (per 1,000 (per (per1,000 (per1,000 (per 1,000 mraiymraiymraiymortality mortality mortality mortality entlPs-entlIfn Under-5 Infant Post-neonatal Neonatal Mortality AIS ak( Rank BASICS) 1998–99 Study 68185221.9 128.5 66.8 mortality accountedfor aboutone-halfofthe mortality about one-halfofinfant mortality, andinfant neonatal mortality, was neonatalmortality was aboutone-halfof neonatal mortality (31% inBoliviaand32%Cambodia).Early 29% occurredduringtheneonatalperiod (40% inBoliviaand43%Cambodia) occurred duringthepost-neonatalperiod 2000). Twenty-eight percentofthesedeaths Cambodia) (Aguilar old (comparedto71%inBoliviaand75% deaths occurredinchildrenlessthan1year s iebrh)livebirths) livebirths) hs) SI)Rn al Rank Tally Rank USAID) 6**32%1 20% 3 16%*** 1986 et al. et 1992 MOH 1997,RACHA group. Malaria isalsoacommoncause of intheneonatalage were reported malaria years group(38%). However, nocases of neonatal group(31%)andthe 1through4 common causeofdeathin boththepost- as ARIordiarrhea.Malariawasthemost malaria andanotherco-existingdiseasesuch malaria, andanother21(6%)weredueto werecausedby cases ofunder-5mortality was malaria.Eighty-three(25%)ofthe330 cause ofdeathinchildrenunder5Guinea facilities. ofdeathsthatoccurinhealth small proportion deaths inthecommunity, ratherthanthe most recent,anditprovidesinformation onall depends onthedatasource. This studyisthe causes ofchilddeathinGuinea. Their ranking asphyxia aretheleading tetanus), andbirth vaccine-preventable diseases(measlesand including thisstudy. accordingtothreedifferent sources,mortality Table causesofchild 5.3ranks theprimary Guinea resultsfrompreventablediseases. in The vast ofillnessand mortality majority Causes ofDeath capture thisdifference. sample sizemayberequiredtoadequately does notreachstatisticalsignificance.Alarger Welch 1997). However, thegenderdifference (Kurz andJohnson- gender-specific mortality finding isconsistentwiththeliteratureof months).among post-neonates(1–11 This of malechildreninallagegroupsexcept who diedwere male. There were moredeaths care andexternalprovidercare. group andpossiblelackofappropriatehome prevalence ofinfectiousdiseasesinthisage couldbeduetoahigh neonatal mortality found inthisstudy. The relatively highpost- deaths duringtheneonatalperiodthanwas of Children expected ahigherproportion less-developed settinglikeGuinea.Savethe distribution followstheexpectedpatternfora (Tabletotal under-5mortality 5.2). This age This studyshowsthatthemostcommon Malaria, ARIs,diarrhea,malnutrition, Fifty-four percent(178/330)ofthechildren disease. diagnosis ofeithermalaria,ARI,ordiarrheal percent ofthechildrenwhodiedhada (3.6%), andmeasles(1.8%).Sixty-two neonatal infections(4.2%),meningitis/sepsis were identifiedincludemalnutrition(6.4%), asphyxia (7%).Othercausesofdeaththat meningitis andsepticemia(8%),birth severe neonatalinfectionsincluding (9%), tetanusfollowedMandiana. bywas This cause ofdeathinchildrenunder5 of death. ranking asthefourth mostcommoncause was lessprevalentinthisagegroup(10%), caused thedeathofneonates; however, it children ages1to4years(16%).ARIalso death amongstpost-neonates(28%)and was thesecondmostcommoncauseof ofadualdiagnosis.with ARIaspart ARI alone (18%),andanother24cases(7%) ARI, with59ofthecasessufferingfromARI causeofchildmortality.the primary prefecture ofMandiana,leadingtomalariaas and poortreatmentisalsoprevalentinthe likely thatthiscombinationofhighprevalence of thesechildrenreceivedchloroquine.Itis thick smeartest(Diallo to havemalaria,diagnosedwithapositive prefecture ofMaferinyah,99(13%)werefound children withfeverinacommunitythe morbidity amongchildreninGuinea.Of748 to strengthen coverageand,inafive-month for measlesantigen. The projectworked hard 15%coveragebaseline KPCsurvey reported studywasconducted,the1997 mortality the MOHandSC/US.One year beforethe strengthening oftheimmunization programby from measlesmaybeduetotherecent Sixty-two percent of the children who died who children the of percent Sixty-two had a diagnosis of either malaria, ARI, or ARI, malaria, either of diagnosis a had diarrheal disease. diarrheal Diarrhea (15%)isthethirdmostcommon The secondhighestcauseofdeathwas The unusually low proportion ofdeaths The unusuallylow proportion et al. et 2001).Only24% 39 DISCUSSION 40 DISCUSSION (Pelletier ofthan one-half childhood deathsworldwide Malnutrition isacontributingfactorinmore recorded inthefacilitymedicalrecord. 62% ofthoseforwhomaweightwas according totheirhealthcards,aswere 57% werefoundtobemalnourished anthropometric informationwaspresent, vaccination coveragelevelof64%. acomplete the SC/US/MOHreported In September1999attheendofstudy, older werecorrectlyvaccinatedformeasles. showing that53%ofthechildren9monthsor children inthestudywhohadhealthcards correlates withtheanalysisof106 olds werecompletelyvaccinated. This that51%of0-to11-month- 1999, reported period betweenNovember1998andMarch differences in thedistributionofdiagnoses of year, presentingonlysmallvariations. demonstrate adefinedpattern throughoutthe septicemia, andneonatalinfections) didnot severe infections(includingmeningitis, tetanus, however, isnotreadilyexplained. The access towater. The trendinneonatal of thedryseasonandmorelimited of diarrhea/dysenteryispredictablebecause occurred inDecember1998. The seasonality most deathscausedbydiarrhea/dysentery neonatal tetanusoccurredinJuly1999,while 1999, andAugust1999).Mostdeathsdueto throughout theyear(October1998,February deaths fromARIpresentedseveralpeaks for ARI,theseasonalityisnotasclear; to malariaoccurredinJulyandAugust,while An expectedseasonalpatternofdeathsdue Age DistributionofDeaths Seasonal, Geographical,and age groupbetween3and5years. an improvementinmalnutritionratesthe increasing withageto2years,followedby malnutrition, withratesofmalnourishment Neonates wereleastlikelytobeaffectedby accepted agedistributionofmalnutrition. note thatthisstudyreflectsthewell- Among childrenforwhom There are important geographical There areimportant et al. et 1995). to Itisalsoimportant the highrates ofmalnutrition. likely thatpoorfoodavailability contributedto meat, fish,bread,orsaltare far away. Itis weekly market.Sourcesof foodslikeas fishing, hunting,orcommerce suchasa zone withlimitedagriculturalresourcesandno nearest healthcenter. poor Saladouisavery Maletoumanina villageis28kmfromthe deaths inSaladousubprefecture. InSaladou, this variation. 29%. There arenoobvious explanations for of allmortality, followed by Mandianawith subprefecture whereARIaccountedfor32% are found inKoundianproportions duetoARI. ofmortality proportion The highest accessibility toappropriatetreatment. mosquitoes aswellproblemsof conditions favorabletohighconcentrationsof deaths duetomalariahasenvironmental of prefectures withthehighestproportion center. Thus, eachofthethreesub- in thestudy, is45kmfromthenearesthealth malaria. Marena,theFaralako villageincluded that suppliesmedicinesfortreatmentof Faralako; however, ofthesystem itisnotpart and theFiéRiver. There isahealthcenterin conditions formosquitoes,includingswamps subprefecture hasfavorableecological km fromahealthcenter, andthis two villagesinKinieransubprefectureis25 higher mosquitodensity. Similarly, oneofthe the SankaraniRiver, whichcontributes toa malaria. The four villagesare1–2kmfrom health centerwheretreatmentisavailablefor two ofwhicharemorethan18kmfroma subprefecture hadfour villagesinthestudy, under 5,witharangeof12%to28%.Morodou causeofdeathamongchildren important other subprefectures,malariawasan Kinieran (37%),andFaralako (36%). Inall main causeofdeathinMorodou(45%), environmental conditions.Malariawasthe services andtothevariationsin accessibility ofpreventiveandcurativehealth may beattributedtothevariationin death inthedifferentsubprefectures,which Malnutrition accounted forMalnutrition 38%ofall Great variationscanbenotedinthe children who were 12monthsorolder. More persistent diarrhea/dysentery occurredin old. Mostofthedeathsdue toacuteor only afew (8)childrenlessthan12months gender were identified. study, nodifferences ininfection ratesby the literature(Benguigui higher ratesofARI/pneumoniaidentifiedin months old,aswellmaleinfants,have 4–6-month-old group(47%).Infantsunder6 Most oftheARIcaseswereidentifiedin for only15%ofthedeathsinthisagegroup. than 4monthsold,thisdiagnosisaccounted cases ofARIwerediagnosedininfantsless deaths analyzed inthisstudy. Even though17 groups andwasresponsiblefor25%ofall serve theminesandhamlets. The MOHmobilevaccinationpostsdonot population residesfor morethanhalftheyear. mines andsmallhamletswherethe Dialakoro isduetotheproliferationofgold health center. The low vaccination coverage in mobile vaccinationpostsfromtheurban explained bythelackofahealthcenterand The lowvaccination coverage inFaralako is coverage levels, 3%and14%respectively. was 36%. Faralako andDialakoro hadlow coverage ofpregnantwomenforMandiana precedingthestudy,period thetetanus toxoid pregnant women.Duringtheeight-month tetanus toxoid vaccination coverage of tetanus correspondstothedistribution of ofdeathsduetoneonatal This distribution no casesofneonataltetanuswere identified. of Koundianakoro, Saladou,andNyantanina, Kantoumanina (13%). Inthesubprefectures (21%), followed by Dialakoro (19%)and ofneonataltetanus the highestproportion tetanus (9%)were identified. Faralako had difficulties inprovidingvaccinationservices. in localminingactivity, whichcontribute to there arelargemovementsofthepopulation Koundianakoro. These aretwoareasinwhich in onlytwosubprefectures,Dialakoroand Diarrhea or dysentery was diagnosedin Diarrhea ordysentery ARI wasdiagnosedinchildrenofallage In thisstudy, 31casesofneonatal Deaths resultingfrommeasleswerefound et al. et 1997).Inthis effectively targeted. the childhealthprogramscanbemore recommendations onhowtheinterventionsof pathway (Figure4.6)andmakes quantifies themainbreakdowns inthe The discussionthatfollows identifiesand forthe determinants thedeathofchild. of and healthproviders) areshown aspart who guardchildren’s well-being(caretakers behaviors oftwodistinctgroupspeople Control andPrevention. Inthismodel,the by BASICS and theU.S. Centersfor Disease data. The Pathway wasdeveloped toSurvival Pathway wasusedtoanalyze the toSurvival The conceptualframework known asthe Pathway toSurvivalAnalysis this age. the introductionofcomplementaryfoodat at 6monthsandolderduetoweaning cases ofdiarrheawouldhavebeenexpected of 52%the children receivedsometype of the dangersignin34%of children.Atotal afterthecaretakerprovided recognized shortly provision ofhomecare.Home carewas The secondstepinthepathway isthe Home Treatment recognized were problematic. when thesesignsandsymptomswere taken (hometreatmentandcare-seeking) pathway tosurvival; however, theactions danger signswasnotamainbreakdowninthe danger signs. The recognitionofillnessand to identifyanumberofthemostimportant serious illness. delayed findingappropriatetreatmentfora sought carefromtraditionalproviders,which caretakers oftenprovidedhomecareor the severity ofthedangersigns. Thus, number ofdangersignsbutnotnecessarily The majorityofcaretakersrecognizeda the caretaker’s recognitionthatthechildisill. The firststepinthecare-seekingprocessis Signs Recognition ofIllnessandDanger With prompting,thecaretakerswereable 41 DISCUSSION 42 DISCUSSION practice ofself-medication. not evaluatetheappropriatenessofthis appropriate insomecases,butthisstudydid included inthehomecaremayhavebeen outsidecare.appropriate medicine The modern but theymayhavedelayedtheseekingof were probablynotdetrimentalinthemselves, traditional herbalbaths/drinksandmassage and waited toseeifthechildimproved. The home careandmodernmedicineinthe (54%). Caretakersoftenprovidedtraditional both traditional(41%)andmodernmedicine treatment). The hometreatmentsconsistedof received onlyhomecare(nooutside outside care.Fifty-eightchildren(18%) sought outsidecareorincombinationwith home treatmenteitherbeforethecaretaker recognition of a certain dangersign andthe recognition of acertain difference couldbefoundbetween the provider thanfrom aformal provider. Noclear more commonlysoughtcare fromatraditional Edmond 2001). fatally illchildren(Hill,Kirkwood,and of 23%(range4–72%)fromninestudies facility. This ismuch higherthanthemedian 40% ofallthechildrenweretakentoahealth area inGuinea,itisimpressivetofindthat the remotenessofmostvillagesinthis from theformalhealthsystem.Becauseof (32%). Only17% of casessoughtcareonly sought careonlyfromtheinformalproviders providers (23%), while alargerproportion from boththeformalandinformalhealth during theillness.Manyfamiliessoughtcare of familiessoughtoutsidecareatsomepoint availability ofhealthcare. (72%) The majority obstacles suchasthegeographical seeking overthecourseofanillness),and traditional healers(57%ofallthecare- automedicate (52%),thehighuseof with severalfactors,includingpreferenceto seeking biomedicalcarewereassociated is inadequate. Inthisstudy, delays in outside thehome.Care-seekinginMandiana The nextstepinthepathwayiscare-seeking Care-Seeking Behavior For mostofthedangersigns, caretakers the accessibility ofhealthfacilities.Lack of providers onthefirstdayof illness. (25.8%) ofcaretakerssought carefromformal the onsetofillness. However, one-third almost days)after 3.5 days(range0–60 at delayed hospitals andhealthcenterswas further average, after2.3days.Care-seekingat caretaker soughtcareforthefirsttime,on an averageof54days.Forallconditions,the recognized thedurationofillnessasbeing any provider, even thoughthecaretaker did notshowamuchhighernumberofvisitsto cases ofchronicconditionslikemalnutrition access toahealthprovider. that Itissurprising baby, poorprobable outcome, anddifficult probably becauseoftheacutecondition taken lessfrequentlytoahealthprovider, with problemsduringthefirstdaysoflifewere durations. hadshorter and malaria Newborns asphyxia, neonatalinfection,tetanus, surprisingly, causesofdeathsuchasbirth of persistentdiarrheainthesegroups.Not respectively, possibly becauseoftheinclusion average durationofillness,26and29days diarrhea anddysenteryhadasurprisinglylong chronic illnesseslikemalnutrition.Both with moreacuteconditionsandthose illness wereevidentbetweenthosechildren was 16.6days. Variations intheduration ofthe diagnoses. The average duration ofallillnesses during agivenillnesswassimilaracrossall healthprovider.from aformal healer. This alsoledtodelays inseekingcare taken morethanonetimetothetraditional were common,andthatthechildwas normally informal providers tocompletethetreatment the caretaker. Itseemsthatfollow-up visitsto the actionstaken andtheproviders visitedby theillnessthatledtodeathdetermined during moment condition ofthechildinacertain given moment. Itisprobable thattheoverall more thanonesymptomordangersignina the otherhand,mostofthesechildrenhad danger signrecognized by thecaretaker). On (analysis was performed onlyfor thefirst typeofprovider consultation ofacertain Closely associatedwithcare-seeking is The number oftimescarewas sought appropriate feeding practices,andtheneed THs arebeingtrained intheuseof ORT, majority ofvillagehealthcommittees, and is vital. SC/UShasincorporated THs inthe treatment, workingwiththe traditionalhealers alone orincombinationwithmodern caretakers soughttraditionaltreatmenteither respiratory infections.Because67.6%ofthe management ofdiarrhealandacute for reinforcingsupport appropriate beliefs withthe THs inordertogaintheir improve chancesforchildsurvival(Nations traditional healers(THs)maybeonewayto Some groupshavefoundthatworkingwith and FormalSources Quality ofCareProvidedbyInformal improve care-seeking behavior. health facilities, willneedtobeaddressed traditional healers, andinaccessibilityof inappropriate automedication,useof and delaystocare-seeking,suchas seeking for severe illness. Specificbarriers on promptrecognitionandappropriatecare- behavior changeinterventionsneedtofocus prevent delays inseekingtreatment. The interventions shouldbestrengthenedto be closelymonitored. system inimprovingaccessibilitywillneedto health carecosts. The effectiveness ofthis from the The communitymemberscanborrowmoney established throughcommunitycontributions. emergency addressed inMandianabytheestablishmentof appropriate servicesandiscurrentlybeing barriertoaccessing This isanimportant as many timesasthesecond,was “no money.” frequently mentionedreason,twice visit public healthproviders. The most There aremanyreasonscaretakersmaynot hours. to ahealthcenterwas2.45 travel time travelling to ahealthfacility. The average timespent reasonsfor thecaretakersimportant notgoing accessibility isconsideredoneofthemost al. 1988). These groups discusstraditional The care-seekingfindingssuggestthat caisses to ahealthpost caisses for both transportation and for bothtransportation , whichwereinitially was 1.46hours and et or elsethehometreatmentprovidedby hospitalization orreferralforadditionalcare, and prescribedhometreatmentinsteadof severity oftheillnessduringconsultation health providerfailedtorecognizethe For thesefourchildren,itisprobablethatthe thereafter.antibiotics andthendiedshortly ORS prescriptionandparenteraloral of thechildrenweresentbackhomewithan account whenthediagnosiswasmade.Four duration ofthediarrheawasnottakeninto records wereanalyzed,itappearedthatthe study. For example, whenthemedical antibiotics weregivenforallARIcases. cases werenotgiven ORT. However, antimalarials, and45%ofsimplediarrhea of themalariacaseswerenotgiven the appropriatetreatment.Forexample,21% the conditionsdiagnosedoftendidnotreceive history takenduringconsultations.Inaddition, majority ofchildrendidnothaveacomplete Children 1997b). Inthe 1997HFA, the conducted inMandiana1997(Save the the healthfacility assessment(HFA) health providers issimilartothedatafound in care. This findingoflow qualityofcareby average care, and29%gave poorquality workers providedgoodcare, 61%gave panel found thatonly10%ofthehealth Guinea, isofteninappropriate. The expert conclude thatmedicalcareinMandiana, review by panelledthisstudyto theexpert themselves detrimental. beliefs andpracticesthatarenotin the positive,ratherthanconfrontingtraditional needtobuildHealth educationefforts upon for timelyreferraltohealthcarefacilities. Efforts should be made to train primary train to made be should Efforts health care providers to diagnose to providers care health preventable and common childhood common and preventable diseases (malaria, pneumonia, diarrhea, pneumonia, (malaria, diseases Similar problemswerenotedinthis The medicalrecordsanalysisandthe measles, and malnutrition), to prescribe the prescribe to malnutrition), and measles, appropriate treatment, or to immediately to or treatment, appropriate refer cases with complications to the district the to complications with cases refer hospital. 43 DISCUSSION 44 DISCUSSION Guinea context. guidelines arecurrentlybeingadaptedtothe Management ofChildhoodIllnesses) child (Costello1997). The IMCI(Integrated guidelines forthemanagementofsick be basedonthenewintegratedclinical training coursesforhealthworkersshould hospital.complications tothedistrict The treatment, ortoimmediatelyrefercaseswith malnutrition), toprescribetheappropriate pneumonia, diarrhea,measles,and common childhooddiseases(malaria, providers todiagnosepreventableand should bemadetotrainprimaryhealthcare managed athealthcarefacilities. Efforts with severesymptomsareadequately medical interventionstoensurethatchildren suggests theneedtoimprovequalityof treatment hadbeeninitiatedintime. This could have beenaverted ifappropriate combination thereof.Itislikelythatdeath 96/130) hadmalaria,diarrhea,ARI,ora by ahealthworker, (73.8%; themajority 39% ofthechildrenexaminedatleastonce en routetoahealthfacility. However, ofthe occurred athome.Eightchildren(3%)died health centersorhospitals,and91% home casemanagement. caretaker didnotmeetthequalitycriteriafor severity oftheir illness. The successof, and neonates werereferredbecause ofthe the childortosendhim her home.Allofthe health worker'sdecisionto referorhospitalize makes itdifficulttojudgethe validityofthe child's deathforeachtypeofdiagnosis with thehealthworker, andthetimeof recognition oftheillnessandconsultation duration ofillness,thetimebetween were referred. The variation between the sent home,10%werehospitalized,and9% the childrenseenbyhealthproviderwere recommendations. Seventy-ninepercentof 81% ofthecaretakersfollowedthese recommendations in97%ofthecases,and Health workersgavetreatment Compliance andReferral Only 6%ofthedeathsoccurredin (Kalter with acceptablesensitivityandspecificity results. Nonetheless,verbalautopsyisatool of themothersinterviewedmaylimit Kumar 1988). Thus, thelow educationalstatus (Datta,Mand,and educated counterparts theeventsreport accurately thantheirless- educatedmothersaremorelikelyreporting; to associated withtheaccuracyoftheir educational statusofthemothershasbeen Zimmer 1976).Itshouldbenotedthatthe to thetimeofdeath(Hoekelman, Kelly, and accurately diagnosetheconditionsproximate fatal canbeusedto illness, andtheirreports recall thesignsandsymptomsoftheirchild’s studies suggestthatmothersareableto the potentialfor recallbias. However, previous data were collectedretrospectively, thereis interpretation oftheresults.First,because Some limitationsshouldbeconsideredinthe Methodology Limitations given atthehealthfacility. were the cases, themedicationsprescribed of medicationatthehealthfacility. In79%of ontheavailability depended atleastpartially compliance with,theprescribedtreatment 1. improve inMandiana, Guinea. childsurvival should considerinfocusing to theirefforts (SC/USandothers) the MOHanditspartners findings andassociatedrecommendationsthat Based uponthestudy, therearefive major Recommendations Conclusions and planning. study resultscanbeusedforprogram toxoid immunization coveragelevelwas promotion ofcleandeliveries. The tetanus with tetanustoxoidandthrough the through improvedmaternal immunization focus onthepreventionof tetanus asphyxia.due tobirth should Efforts neonatal tetanus,andanother24%were percent ofthesedeathsweredueto deaths wereinneonates. Almost one-third(29%)oftheunder-5 et al. et 1991,Marsh et al. al. et Thirty-two 1995), andthe 3. 2. facilities isa majorconcern. the qualityofcaretheyreceived inthese study didvisitaformal health facility, of thechildreninthis Although 40% workers todistributeantimalarials. required toenablecommunity-based setting. Advocacyatthepolicylevelis countries andshouldbeconsideredinthis proven tobesafeandeffectiveinother medication. These approacheshave been fever build ontheexisting practiceofself- workers andthehomemanagementof case managementby villagehealth the rainy season,isabarrier. Community where treatmentisavailable, especiallyin the populationfromhealthcenters duetomalaria.mortality The distanceof factor inaddressing second important Access toappropriatetreatmentisthe promotion anddistributionprogram. needs tobeaddressedbyabednet both supplyanddemand;thisproblem Mandiana (lessthan10%)for reasonsof insecticide-treated bednetsislowin mortality.high rateofmalaria The useof need tobestrengthenedimpactonthe Both preventive andcurative services deaths wereassociatedwithmalaria. Almost one-third(31.5%)ofunder-5 impact ofcommunity-based interventions. needed inthisareatodocumentthe but additionaloperationsresearchis perform simpleresuscitationtechniques, asphyxia andto recognition ofbirth include training of TBAs toimprove asphyxia, can efforts deaths duetobirth address neonataltetanus. To address deliveries by thetraining of TBAs willalso The currentstrategy ofpromotingclean the outreachofmobilevaccination posts. farming, couldbeaddressedbyextending gold minesandtothesmallhamletsfor such asthemovement of women tothe toachievingbarriers highercoverage, improved dramaticallysincethen. The 36% precedingthestudyandhasnot Efforts are Efforts 4. “labeled” bythe caretakersassevereor means thatthesymptomwas not for outsidecare, formal ortraditional. This the childreninstudywere nottaken recognized severeillness) or 28%ofall these children(whosecaretakers a healthprovider. Yet (25%)of one-quarter standards, shouldleadtoseekingcareat symptom that,accordingtointernational child hadoneormoredangersignsa caretakers (88%)recognizedthattheir severity wasabitproblematic.Most of the illnesswas labeledinterms recognized theirchildrenwere ill,but how this study, allcaretakers initially tocare.labeling ofillness, andresort In of care-seeking:recognitionillness, There arethreeinterlinked components providers.”seek carefromappropriate need treatmentoutsidethehomeand WHO as“Recognizewhensickchildren IMCI strategy. This practiceisdefinedby identified by WHO andUNICEFinthe care-seeking, oneofthe12keypractices examine needtocritically The partners appropriate care-seekingisessential. visited ahealthfacility, improving For the60%ofchildrenwhonever would otherwisenotseekcare. utilization ofhealthservicesbythosewho also havethecollateraleffectofincreasing Survival. Improvingthequalityofcaremay deceased childreninthePathway to outcomes ofoverone-thirdthe have hadthepotentialforimproving of facility-basedIMCItreatmentwould “average” treatment.Improvingthequality treatment forthe24%whoreceived the facilities.Itwouldalsohaveimproved children whoreceived“poor”treatmentin quality ofcarethe12%330 training wouldhavedirectlyimpactedthe health workers intheIMCIprotocols. This in healthfacilitiesbytrainingperipheral IMCI strategyimprovesthequalityofcare provided atfirst-level facilities. The current needed toimprovethequalityofcare 45 DISCUSSION 46 DISCUSSION 5. providers whoareboththefirstoutside care-seeking istheuseoftraditional contributor toinappropriate important the dangersign.Anotherevenmore afterrecognizing 38% soughtcareshortly caretakers delayedseekingcare.Only recognized dangersigns, many ofthese for outsidecarebecausethecaretaker Although 72%ofthechildrenweretaken center/post (26%ofrespondents). togoingahealth barrier important in somecases,medication)isthemost pay for consultation,and, transportation, need tobeaddressed. is influencedbyotherfactorsthatalso The resort-to-carestepofcare-seeking this stepinthePathway toSurvival. change communications would address labeling ofdangersignsthroughbehavior improve caretakers'recognitionand outside care.Aprogrammaticapproachto dangerous enoughtowarrantseeking Lack ofmoney(to children. be expanded toincludeseverely ill this studyindicatethatthesystemshould emergencies. However, thefindingsof strategy hasbeenfocused onobstetrical mechanisms throughtheCVSs. This fundsand emergency transport points. The secondstrategyistoorganize refer patientstohealthcentersor THs willrecognizesevereillnessand adaptation andfollow-up toensurethat oftheCVSs.part This trainingrequires incorporate andtraintraditionalhealersas Mandiana. The first strategy isto developed by theMOHandSC/USin value oftwo ofthecurrentstrategies respondents). the This findingaffirms not becuredbymodernmedicine(13%of signs butbelievedthattheillnesscould Many caretakers recognized thedanger the illness(57%ofallcare-seeking). commonly consultedduringthecourseof provider consultedandthemost References

Aguilar, A. M., R. Alvarado, D. Cordero, P. Kelly, A. Hoekelman, R. A., J. Kelly, and A. W. Zimmer. Zamora, and R. Salgado. 1997. Mortality 1976. The reliability of maternal recall: Mothers' Survey in Bolivia: Investigating and Identifying remembrance of their infant's health and the Causes of Death for Children Under 5. illness. Clinical Pediatrics (March):261–265. Arlington, Va.: BASICS. Kalter, H. D., R. H. Gray, R. E. Black, and S. A. Bellamy, Carol. 1996. The State of the World's Gultiano. 1991. Validation of the diagnosis of Children 1997. New York: Oxford University childhood morbidity using maternal health Press. interviews. International Journal of ———. 1999. The State of the World's Children Epidemiology 20(1):193–198. 2000. New York: Oxford University Press. Kurz, K. M., and C. Johnson-Welch. 1995. Child ———. 2001. The State of the World's Children Survival and Improving the Health Status of the 2000. New York: Oxford University Press. Girl-Child. Review paper. Arlington, Va.: BASICS. Benguigui, Y., F. Antuñano, G. Schmunis, and J. Yunes. 1997. Respiratory Infections in Children. Marsh, D., K. Husein, M. Lobo, M. Ali Shah, and Washington, D.C.: Pan American Health S. Luby. 1995. Verbal autopsy in Karachi slums: Organization. Comparing single and multiple causes of child deaths. Health Policy and Planning 10(4):395– Bureau National de Recensement. Dec. 1996. 403. Recensement General de la Population et de l'Habitat. Conakry, Guinea. National Office of Statistics and Macro International, Inc. 2000. Demographic and Center for International Health Information (CIHI). Health Survey Guinea 1999. Calverton, Md.: 1995. Guinea Country Health Profile 1995. National Office of Statistics and Macro Arlington, Va.: Information Management International. Consultants, Inc. Nations, M. K., M. A. de Sousa, L. L. Correia, and Costello, A. 1997. Integrated management of D. M. Silva. 1988. Brazilian popular healers as childhood illness. Lancet 350(9087):1266. effective promoters of oral rehydration therapy Datta, N., M. Mand, and V. Kumar. 1988. (ORT) and related child survival strategies. Pan Validation of causes of infant death in the American Health Organization Bulletin community by verbal autopsy. Indian Journal of 22(4):335–351. Pediatrics 55:599–604. Pelletier, D. L., E. A. Frongillo, Jr., D. B. Schroeder, Diallo, A. B., G. De Serres, A. H. Béavogui, C. and J-P. Habicht. 1995. The effects of Lapointe, and P. Viens. 2001. Home care of malnutrition on child mortality in developing malaria-infected children of less than 5 years of countries. Bulletin of the World Health age in a rural area of the Republic of Guinea. Organization 73:443–48. Bulletin of the World Health Organization Reproductive and Child Health Alliance (RACHA). 79(1):28–32. 2000. The Pathway to Child Health: Siem Gray, R., G. Smith, and P. Barss. 1990. The Use of Reap, Pursat, Stung Treng, and Kampot. Verbal Autopsy Methods to Determine Selected Research Report. Cambodia. Causes of Death in Children. Occasional Paper Save the Children. 1997a. Guinea Child Survival No. 10. Baltimore, Md.: The Johns Hopkins Baseline Survey XII. University School of Public Health Institute for International Programs. ———. 1997b. Guinea Health Facilities Assessment Child Survival XII. Hill, Z., B. Kirkwood, K. Edmond. 2001. Family and Community Practices That Promote Child World Health Organization (WHO). 1996. Survival, Growth and Development—A Review Perinatal mortality: A listing of available of the Evidence. London, England: London information. WHO document, Geneva. School of Hygiene and Tropical Medicine. REFERENCES

47

Annex A Verbal Autopsy Questionnaire

Child’s Identification Number ______

Instructions to surveyor: Section 1 below will be complete when your supervisor gives you the questionnaire. The Verbal Autopsy Surveyor's Procedures Manual explains how to use this information to help you conduct the interview. Complete Section 2 according to the instructions in the procedures manual. The actual interview starts with section 3.

Section 1: Background information from animator 1.1 Animator’s code number ______/____/____

1.2 Address of household: Notes to find the concession ______1.2.1 Quartier/Commune: ______Code: ______1.2.2 District: ______Code: ______1.2.3 Secteur: ______Code: ______1.2.4 Sous-prefecture: ______Code: ______

1.3 Name of child ______

1.4 Sex of child...... 1. Male ___ 2. Female ___

1.5 Date of report...... ______/______/______( d d / m m / y y )

1.6 Child’s age at time of death: 1.6.1 Age in completed days (if less than 28 days) ...... days ______1.6.2 Age in completed months (if 28 days or more) ...... months ______

Section 2: Information about the interview 2.1 Language of the interview ______

2.2 Surveyor’s code number ____/____ Date of first interview ____/____/____ attempt 2.3 Date of interview ____/____/____ Date and time arranged for ____/____/____ second interview attempt Date form checked ____/____/____ Date and time arranged for ____/____/____ by supervisor third interview attempt Date entered in computer ____/____/____ Date interview abandoned ____/____/____ ANNEX A

49 Child’s Identification Number ______

Instructions to surveyor: Introduce yourself and explain the purpose of your visit. Say that you are interested in the illness that led to death. Ask to speak to the person who was the child’s main caregiver during the illness. If this is not possible, arrange a time to revisit the household when this person will be home.

Section 3: Background information from caretaker

3.1 “What is your name?” ______

3.2 “What is your relationship to _____?” ...... 1. Mother ___ 2. Father ___ 3. Co-mother ___ 4. Grandmother ___ 5. Grandfather ___ 6. Aunt ___ 7. Uncle ___ 8. Other male (specify ) ___ 9. Other female (specify ) ___

3.3 Who was _____’s usual caretaker? ...... 1. Mother ___ 2. Father ___ 3. Co-mother ___ 4. Grandmother ___ 5. Grandfather ___ 6. Aunt ___ 7. Uncle ___ 8. Other male (specify ) ___ 9. Other female (specify ) ___

3.4 Record whether other persons are present at the interview or not ...... 1. Yes, other persons present ___ ...... 2. No, only the respondent is present ___ (If “No”, go to 3.5)

3.4.1 “Of the persons in the room with us now, who helped care for the child during his/her illness?” Present at interview Helped care for child 1. Mother ______2. Father ______3. Co-mother ______4. Grandmother ______5. Grandfather ______6. Aunt ______7. Uncle ______8. Other male (specify ______) ______9. Other female (specify ______) ______ANNEX A

50 Child’s Identification Number ______

3.5 If mother is not present at the interview, ask: “Is _____’s mother still alive?” ... 1. Yes ___ 2. No ___ 8. Don’t know ___

3.6 “What is your age (in years)?” ...... years ______(Don’t know = 88) (If respondent is the mother, go to 3.7) 3.6.1 If respondent is not the mother, ask: “What is/was _____’s mother’s age?” (now or at time of death) ...... years ______(Don'’ know = 88)

3.7 “Did you go to school?” ...... 1. Yes ___ 2. No ___ (If “No,” go to 3.7.1) 3.7.A “What was the highest level you achieved?” ...... 1. Primary ___ 2. Secondary ___ 3. Superior (university) ___ 4. Professional (trade school) ___ (If respondent is the mother, go to 3.8) 3.7.1 If respondent is not the mother, ask: “Did _____’s mother go to school?” ...... 1. Yes ___ 2. No ___ 8. Don’t know ___ (If “No” or “Don’t know,” go to 3.8) 3.7.1.A “What is the highest level that she achieved?” ...... 1. Primary ___ 2. Secondary ___ 3. Superior (university) ___ 4. Professional (trade school) ___ 8. Don’t know ___

3.8 “What is your occupation?” ______3.8.A “Do you do farming?” ...... 1. Yes ___ 2. No ___ (If “No,” go to 3.8.B) 3.8.A.1 “Do you work on ...... 1. your own or your family’s field ___ (Slowly read the choices and mark 2. a cooperative field ___ the one best choice.) 3. a borrowed field ___ 4. someone else’s field ___ 3.8.B “Do you go to the mines for work?” ...... 1. Yes ___ 2. No ___ (If “No,” go to 3.8.1) 3.8.B.1 “In the last 12 months, how much time have you spent working in the mines?” ...... days (if less than one month) ______months (if one month or more) ______(Don’t know = 88) ANNEX A

51 Child’s Identification Number ______

3.8.B.2 “When you go to work at the mines, do you sleep there or return home each day?” ... 1. Always sleep at the mines ___ 2. Sometimes sleep at the mines ___ 3. Always return home ___ 4. Other (specify ______) ___ 3.8.B.3 “During the three months before _____’s death, did (s)he ever go to the mines with you?” .... 1. Yes, always went to the mines ___ 2. Yes, child sometimes went ___ 3. No, child never went ___ 4. No, I didn’t go to mines during the last 3 months ___ (If “Yes, always went,” go to 3.8.1)

3.8.B.3.1 “During the three months before _____’s death, who cared for the child when you were at the mines?” ... 1. Mother ___ (Multiple answers allowed.) 2. Father ___ 3. Co-mother ___ 4. Grandmother ___ 5. Grandfather ___ 6. Aunt ___ 7. Uncle ___ 8. Other male (specify ______) ___ 9. Other female (specify ______) ___ (If respondent is the mother, go to 3.9)

3.8.1 If respondent is not the mother, ask: “What is/was (if deceased) the mother's occupation?” ______3.8.1.A “Does/did (if deceased) the mother do farming?” ...... 1. Yes ___ 2. No ___ 8. Don’t know ___ (If “No” or “Don’t know,” go to 3.8.1.B) 3.8.1.A.1 “Does/did (if deceased) the mother work on ...... 1. her own or her family’s field ___ (Slowly read the choices and 2. a cooperative field ___ mark the one best choice.) 3. a borrowed field ___ 4. someone else’s field ___ 8. Don’t know ___ 3.8.1.B “Does/did (if deceased) the mother go to the mines for work?” ...... 1. Yes ___ 2. No ___ 8. Don’t know ___ (If “No” or “Don’t know,” go to 3.9) 3.8.1.B.1 “In the last 12 months, how much time did the mother spend working in the mines?” ...... days (if less than one month) ______months (if one month or more) ______(Don’t know = 88) ANNEX A

52 Child’s Identification Number ______

3.8.1.B.2 “When the mother goes/went (if deceased) to work at the mines, does/did she sleep there or return home each day?” ...... 1. Always sleep at the mines ___ 2. Sometimes sleep at the mines ___ 3. Always return home ___ 4. Other (specify ______) ___ 3.8.1.B.3 “During the three months before _____’s death, did (s)he ever go to the mines with the mother?” ...... 1. Yes, always went to the mines ___ 2. Yes, child sometimes went ___ 3. No, child never went ___ 4. No, mother didn't go to mines during the last 3 months ___ (If “Yes, always went,” go to 3.9) 3.8.1.B.3.1 “During the three months before _____’s death, who cared for the child when the mother was at the mines?” ...... 2. Father ___ (Multiple answers allowed) 3. Co-mother ___ 4. Grandmother ___ 5. Grandfather ___ 6. Aunt ___ 7. Uncle ___ 8. Other male (specify ______) ___ 9. Other female (specify ______) ___

Instructions to surveyor: Questions 3.9 to 3.13 are about the child's mother. If the respondent is the mother, read the questions as “...have you...,” “...do you...,” or “...of your...” “If the respondent is not the mother, read the questions as “...has _____’s mother..., ”does _____’s mother...,” or _____’s mother...”

3.9 “How many times have you/has _____’s mother been pregnant?" ...... number of times ______(Don’t know = 88)

3.10 “How many times have you/has _____’s mother given birth (including _____)?” ...... number of times ______(Don’t know = 88)

3.11 “How many living children do you/does _____’s number of living children ______mother have now?” (Don’t know = 88)

3.12 “How many of your/_____’s mother’s number of deceased children ______children have died (including _____)?” (Don't know = 88)

3.13 “Do you/does _____’s mother belong to a community organization?” ...... 1. Yes ___ 2. No ___ 8. Don’t know ___ (If “No” or “Don’t know,” go to 3.14) ANNEX A

53 Child’s Identification Number ______

3.13.1 If “Yes,” ask: “What is its name?” ______3.13.2 “What does the organization do?” ______

3.14 “What is/was _____’s father’s age ...... years ______(in years, now or at time of his death)?” (Don’t know = 88)

3.15 “Did _____’s father go to school?” ...... 1. Yes ___ 2. No ___ 8. Don’t know ___ (If “No” or “Don’t know,” go to 3.16) 3.15.A “What was the highest level that he achieved?” ...... 1. Primary ___ 2. Secondary ___ 3. Superior (university) ___ 4. Professional (trade school) ___ 8. Don’t know ___

3.16 “What is/was the father’s occupation?” ______3.16.A “Does/did (if deceased) the father do farming?” ...... 1. Yes ___ 2. No ___ 8. Don’t know ___ (If “No” or “Don’t know,” go to 3.18) 3.16.A.1 “Does/did (if deceased) the father work on...... 1. his own or his family’s field ___ (Slowly read the choices and 2. a cooperative field ___ mark the one best choice.) 3. a borrowed field ___ 4. someone else’s field ___ 8. Don’t know ___

3.17 NOTHING

3.18 “What language is spoken most often in the household where _____ lived?”______

______

3.19 “At the time that _____ died, for how long had the (husband's) family (menage) lived in their current house?”...... months/years ______(Circle the correct word) (Don’t know = 88) ANNEX A

54 Child’s Identification Number ______

3.20.A “In the household where _____ lived, what are all the water sources used for washing hands and dishes in the rainy and dry seasons?” ...... 1. Pump in the house/compound ___ (Multiple answers allowed) 2. Public pump ___ 3. Private well ___ 4. Public well ___ 5. Spring ___ 6. Seasonal lake ___ 7. Marsh/lake ___ 8. River ___ 9. Rain water ___ 10. Other (specify ______) ___

3.20.B “In the household where _____ lived, what are all the sources of drinking water during the rainy and dry seasons?” ...... 1. Pump in the house/compound ___ (Multiple answers allowed) 2. Public pump ___ 3. Private well ___ 4. Public well ___ 5. Spring ___ 6. Seasonal lake ___ 7. Marsh/lake ___ 8. River ___ 9. Rain water ___ 10. Other (specify ______) ___

3.21.A “What is the floor made of in the house where _____ lived?” ...... 1. Wood/cement ___ 2. Earth ___ 8. Don’t know ___

3.21.B “What is the roof made of where _____ lived?” ...... 1. Tin ___ 2. Straw ___ 8. Don’t know ___

3.22 “In the household (foyer—immediate family) where _____ lived, how many rooms were used for sleeping?” ...... number of rooms ___ (Don’t know = 88)

3.23 “Including _____, how many people lived in the household (foyer—immediate family)?” ...... number of people ______(Don’t know = 88)

3.24 “What is the name of the health facility where _____ was usually taken for his/her care?” ______3.24.1 “How long does it usually take to reach there?” minutes/hours ______(Circle the correct word) (Don’t know = 888) ANNEX A

55 Child’s Identification Number ______

Section 4: Information about the child

4.1 “Can you tell me _____’s date of birth?” ...... ______/______/______( d d / m m / y y )

4.2 “Where was _____ born?” ...... 1. Home ___ 2. Health post ___ 3. Health center ___ 4. Hospital ___ 5. Other (specify ______) ___ 8. Don’t know ___ 4.2.1 “Who attended the birth?”...... 1. No one ___ 2. Trained TBA ___ 3. Un-trained TBA ___ 4. Health agent ___ 5. Other (specify ______) ___ 8. Don’t know ___

4.3 “How many children did you/_____’s mother have ...... number ______before _____ was born?” (Don’t know = 88)

4.4 “Can I please see _____’s health card?” ...... 1. Yes ___ 2. No, or don't have a health card ___ 8. Don’t know if have a health card ___ (If “No” or “Don’t know,” go to 4.5)

Mark whether each antigen was given:

4.4.0 BCG ...... 1. Yes ___ 4.4.5 DPT1 ...... 1. Yes ___ 2. No ___ 2. No ___ 4.4.1 Polio 0...... 1. Yes ___ 4.4.6 DPT2 ...... 1. Yes ___ 2. No ___ 2. No ___ 4.4.2 Polio 1...... 1. Yes ___ 4.4.7 DPT3 ...... 1. Yes ___ 2. No ___ 2. No ___ 4.4.3 Polio 2...... 1. Yes ___ 4.4.8 Measles...... 1. Yes ___ 2. No ___ 2. No ___ 4.4.4 Polio 3...... 1. Yes ___ 2. No ___

4.4.9 Record the last weight from the health card ...... kilograms ______.____ (No weight recorded = 88.8) 4.4.10 Record the date of the last weight ...... ______/______/______( d d / m m / y y ) ANNEX A

56 Child’s Identification Number ______

4.5 “Was _____ ever breastfed?” ...... 1. Yes ___ 2. No ___ 8. Don’t know ___ (If “No” or “Don’t know,” go to 4.6) 4.5.1 If “Yes,” ask: “For how many months did _____ drink only breastmilk?” ...... months ______. ______(Don’t know = 88.88) 4.5.2 If “Yes,” ask: “How old (in months) was _____ when (s)he stopped breastfeeding?” ...... months ______. ______(Don’t know = 88.88)

4.6 “What was the date of _____’s death?” ...... ______/______/______( d d / m m / y y )

4.7 “How many days long was the illness that led to _____’s death?”...... days ______

4.8 “During the month before _____’s death, did you seek care for him/her outside the home?”...... 1. Yes ___ 2. No ___ (If “No,” go to 4.11) If “Yes,” ask: “Where or from whom did you seek care? Did you seek care from... 4.8.1 a traditional healer (including a TBA)?”...... 1. Yes ___ 2. No ___ 4.8.2 a religious leader? ...... 1. Yes ___ 2. No ___ 4.8.3 a health center, health post or dispensary...... 1. Yes ___ 2. No ___ (If “No,” go to 4.8.4) 4.8.3.1 If “Yes” for health center, health post or dispensary, ask: “What is the name and address of the facility?” ______

4.8.4 a hospital? ...... 1. Yes ___ 2. No ___ (If “No,” go to 4.8.5) 4.8.4.1 If “Yes” for hospital, ask: “What is the name and address of the hospital?” ______4.8.5 NOTHING 4.8.5.1 NOTHING 4.8.6 a private physician? ...... 1. Yes ___ 2. No ___ (If “No,” go to 4.8.7) ANNEX A

57 Child’s Identification Number ______

4.8.6.1 If “Yes” for private physician, ask: “What is the physician's name and address?” ______4.8.7 a pharmacy, drug seller, store, market? ...... 1. Yes ___ 2. No ___ 4.8.8 NEANT 4.8.9 a relative or friend outside the household ...... 1. Yes ___ 2. No ___

(If no care was sought outside the home, go to 4.11) 4.9 “How many days was _____ ill before you first sought care for the illness outside the home?”...... days ______

(If no care was sought at a formal health facility, go to 4.11) 4.10 “How many days was (s)he ill before you first sought care at a hospital or other health facility?” ...... days ______

4.11 “Where did _____ die?” 1. Hospital ___ 2. Other health facility ___ 3. On route to hospital or other health facility ___ 4. Home ___ 5. Other (specify ______) ___ (If “On route to hospital or other health facility,” “Home,” or “Other,” go to Section 5) For deaths at hospital or other health facility, ask: 4.11.1 “What is the facility name and address?” ANNEX A

58 Child’s Identification Number ______

Section 5: Open history question

“Could you tell me briefly about your child's illness that led to death?”

Prompt: “Was there anything else?”

Instructions to surveyor: Allow the respondent to tell you about the illness in his or her own words. Do not prompt except for asking whether there was anything else. ANNEX A

59 Child’s Identification Number ______

5.1 Tick all items mentioned spontaneously:

5.1.1 ...... Diarrhea (local terms: ______, ______) ___

5.1.2 ...... Cough (local terms: ______, ______) ___

5.1.3 ...... Fever (local terms: ______, ______) ___

5.1.4 ...... Rash (local terms: ______, ______) ___

5.1.5 ...... Injury (local terms: ______, ______) ___

5.1.6 ...... Coma (local terms: ______, ______) ___

5.1.7 ...... Convulsion (local terms: ______, ______) ___

5.1.8 ...... Stiff neck (local terms: ______, ______) ___

5.1.9 ...... Tetanus (local terms: ______, ______) ___

5.1.10 ...... Measles (local terms: ______, ______) ___

5.1.11 ...... Kwashkiorkor (local terms: ______, ______) ___

5.1.12 ...... Marasmus (local terms: ______, ______) ___

5.1.13 ...... Difficult breathing (local terms: ______, ______) ___

5.1.14 ...... Fast breathing (local terms: ______, ______) ___

5.1.15 ...... Wheezing (local terms: ______, ______) ___

5.1.16 ...... Complicated delivery (local terms: ______, ______) ___

5.1.17 ...... Malformation (local terms: ______, ______) ___

5.1.18 ...... Multiple birth (local terms: ______, ______) ___

5.1.19 ...... Very small at birth (local terms: ______, ______) ___

5.1.20 ...... Very thin (local terms: ______, ______) ___

5.1.21 ...... Born early (local terms: ______, ______) ___

5.1.22 ...... Pneumonia (local terms: ______, ______) ___

5.1.23 ...... Malaria (local terms: ______, ______) ___

5.1.24 ...... Jaundice (local terms: ______, ______) ___

5.1.25 ...... Abdominal pain (local terms: ______, ______) ___

5.1.26 ...... Other terms (specify: ______, ______, ______, ______) ___ ANNEX A

60 Child’s Identification Number ______

Section 6: Injury

6.1 “Did _____ die from an injury, bite, burn, poisoning or drowning?” ...... 1. Yes ___ 2. No ___ 8. Don’t know ___ (If “No” or “Don’t know,” go to Section 7) 6.1.1 If “Yes,” ask: “What kind of injury?” ...... 1. Motor vehicle accident ___ 2. Fall ___ 3. Drowning ___ 4. Poisoning ___ 5. Bite or sting by venomous animals ___ 6. Burn ___ 7. Violence ___ 8. Birth injury ___ 9. Other injury (specify ______) ___ 6.1.2 If “Yes,” ask: “Did _____ die within 24 hours of this injury?” ...... 1. Yes ___ 2. No ___

IF “YES, DIED WITHIN 24 HOURS,” GO TO SOCIAL AUTOPSY

IF “NO,” CONTINUE WITH SECTION 7

Section 7: Age Determination

7.1 Record the child’s date of birth from question 4.1 ...... ______/______/______( d d / m m / y y )

7.2 Record the child’s date of death from question 4.6 ...... ______/______/______( d d / m m / y y )

7.3 Determine the age: Mark the child’s age in months at the time of death: ...... 1. Less than one month ___ [Subtract the birth date (question 7.1) from the date 2. One month or more ___ of death (question 7.2)] 7.3.1 “I have calculated that _____ was ______days/months old when (s)he died. Is this correct?”...... 1. Yes ___ (Circle the correct word) 2. No ___

IF “ONE MONTH OR MORE,” SKIP TO SECTION 9. POSTNEONATAL DEATHS IF “LESS THAN ONE MONTH,” CONTINUE WITH SECTION 8. NEONATAL DEATHS

Section 8: Neonatal deaths

8.1 Record the child’s age in days at the time of death (from question 7.3.1) ...... days ______ANNEX A

61 Child’s Identification Number ______

8.2 “Did this child’s pregnancy end early, on time, or late?” ...... 1. Early ___ 2. On time ___ 3. Late ___ 8. Don’t know ___

8.3 “Did the waters break before labor or during labor?”...... 1. Before ___ 2. During ___ 8. Don’t Know ___ (If “During” or “Don’t know”, go to 8.4) 8.3.1 If waters broke before labor ask: “How much time before labor began did the waters break?” ...... 1. Less than one day ___ 2. More than one day ___

8.4 “Did (s)he have any malformations at birth?” ...... 1. Yes ___ 2. No ___ 8. Don’t know ___ (If “No” or “Don’t know,” go to 8.5) If “Yes,” ask: “Where were the malformations? Were they on the: 8.4.1 head?” ...... 1. Yes ___ 2. No ___ 8.4.2 body?” ...... 1. Yes ___ 2. No ___ 8.4.3 arms or hands?” ...... 1. Yes ___ 2. No ___ 8.4.4 legs or feet?” ...... 1. Yes ___ 2. No ___

8.5 “At the time of birth was _____ ...... 1. Very small? ___ (Read all the possible answers to the respondent) 2. Smaller than usual? ___ 3. About average? ___ 4. Larger than usual? ___

8.6 “Was _____ able to breathe after the birth?” ...... 1. Yes ___ 2. No ___ 8. Don’t know ___

8.7 “Was _____able to suckle in a normal way after birth?” ...... 1. Yes ___ 2. No ___ 8. Don’t know ___ (If “No” or “Don’t know,” go to 8.8) 8.7.1 If “Yes,” ask: “Did _____ stop suckling?” ...... 1. Yes ___ 2. No ___ (If “No” or “Don’t know,” go to 8.8) 8.7.1.1 If “Yes,” ask: “How many days after birth did _____ stop suckling?” ...... days ______ANNEX A

62 Child’s Identification Number ______

8.8 “Was _____able to cry after birth?” ...... 1. Yes ___ 2. No ___ 8. Don’t know ___ (If “No” or “Don’t know,” go to 8.9) 8.8.1 If “Yes,” ask: “Did _____ stop being able to cry?” ...... 1. Yes ___ 2. No ___ (If “No” or “Don’t know,” go to 8.9) 8.8.1.1 If “Yes,” ask: “How many days after birth did _____ stop crying?” ...... days ______

8.9 “During the illness that led to death, did _____ have spasms or convulsions?” ...... 1. Yes ___ 2. No ___

8.10 “During the illness that led to death, did s(he) become unresponsive/unconscious?” ...... 1.Yes ___ 2. No ___ 8. Don’t know ___

8.11 “During the illness that led to death, did (s)he have a bulging fontanelle?” ...... 1.Yes ___ 2. No ___ 8. Don’t know ___

8.12 “During the illness that led to death, did _____ have ...... 1.Yes ___ redness or drainage from the umbilical cord stump?” 2. No ___ 8. Don’t know ___

8.13 “During the illness that led to death, did (s)he have a skin rash with bumps containing pus?” ...... 1.Yes ___ 2. No ___ 8. Don’t know ___

8.14 “During the illness that led to death, did _____ have a fever?” ...... 1. Yes ___ 2. No ___ 8. Don’t know ___ (If “No” or “Don’t know,” go to 8.15) 8.14.1 If “Yes,” ask: “How many days did the fever last?” ...... days ______

8.15 “During the illness that led to death, did _____ have frequent liquid, watery or loose stools? ...... 1. Yes ___ 2. No ___ 8. Don’t know ___

8.16 “During the illness that led to death, did _____ have (local terms for diarrhea: ______, ______)?” ...... 1. Yes ___ 2. No ___ 8. Don’t know ___ (If “No” or “Don’t know” for 8.15 and 8.16, go to 8.17) ANNEX A

63 Child’s Identification Number ______

If “frequent liquid, watery or loose stools or local term for diarrhea,” ask: 8.16.1 “For how many days did (s)he have liquid/watery/loose stools?” ...... days ______8.16.2 “Was there visible blood in the liquid/watery/loose stools?”...... 1. Yes ___ 2. No ___ 8. Don’t know ___

8.17 “During the illness that led to death, did _____ have a cough?” ...... 1. Yes ___ 2. No ___ 8. Don’t know ___ (If “No” or “Don’t know,” go to 8.18) 8.17.1 If “Yes,” ask: “For how many days did the cough last?” ...... days ______

8.18 “During the illness that led to death, did _____ have difficult breathing?”...... 1. Yes ___ 2. No ___ 8. Don’t know ___ (If “No” or “Don’t know,” go to 8.19) 8.18.1 If “Yes,” ask: “For how many days did the difficult breathing last?” ...... days ______

8.19 “During the illness that led to death, did _____ have fast breathing?” ...... 1. Yes ___ 2. No ___ 8. Don’t know ___

8.20 “During the illness that led to death, did _____ have indrawing of the chest?” ....1. Yes ___ (Demonstrate chest indrawing) 2. No ___ 8. Don’t know ___

GO TO SOCIAL AUTOPSY QUESTIONNAIRE

Section 9: Postneonatal deaths 9.1 Record the child’s age in completed months at the time of death (from question 7.3.1) ...... Number of completed months ______

9.2 “During the last month of the illness that led to death, did _____ have a fever?” ...... 1. Yes ___ 2. No ___ 8. Don’t know ___ (If “No” or “Don’t know”, go to 9.3) 9.2.1 If fever, ask: “How many days did the fever last?” ...... days ______

9.3 “During the last month of the illness that led to death, did _____ have frequent liquid, watery or loose stools?” ...... 1. Yes ___ 2. No ___ 8. Don’t know ___ ANNEX A

64 Child’s Identification Number ______

9.4 “During the last month of the illness that led to death, did (s)he have (local terms for diarrhea:______, ______)?” ...... 1. Yes ___ 2. No ___ 8. Don’t know ___ (If “No” or “Don’t know” for 9.3 and 9.4, go to 9.5) If frequent liquid/watery/loose stools or local term for diarrhoea, ask: 9.4.1 “For how many days did (s)he have liquid/watery/loose stools?” ...... days ______9.4.2 “Was there visible blood in the liquid/watery stools?” ...... 1.Yes ___ 2. No ___ 8. Don’t know ___

9.5 “During the last month of the illness that led to death, did ______have a cough?” ...... 1. Yes ___ 2. No ___ 8. Don’t know ___ (If “No” or “Don’t know”, go to 9.6) 9.5.1 If “Yes”, ask: “For how many days did the cough last?” ...... days ______

9.6 “During the last month of the illness that led to death, did ______have difficult breathing?” ...... 1. Yes ___ 2. No ___ 8. Don’t know ___ (If “No” or “Don’t know”, go to 9.7) 9.6.1 If “Yes”, ask: “For how many days did the difficult breathing last?” ...... days ______

9.7 “During the last month of the illness that led to death, did ______have fast breathing?” ...... 1. Yes ___ 2. No ___ 8. Don’t know ___

9.8 “During the last month of the illness that led to death, did _____ have indrawing of the chest?” ...... 1. Yes ___ 2. No ___ 8. Don’t know ___

9.9 “Did ______experience any generalized convulsions during the last month of the illness that led to death?” ...... 1. Yes ___ (Demonstrate a generalized convulsion) 2. No ___ 8. Don’t know ___

9.10 “Was ______unconscious at any time during the last month of the illness that led to death?” ...... 1. Yes ___ 2. No ___ 8. Don’t know ___ ANNEX A

65 Child’s Identification Number ______

9.11 “At any time during the last month of the illness that led to death, did ______stop being able to grasp?” ...... 1. Yes ___ 2. No ___ 8. Don’t know ___ (If “No” or “Don’t know,” go to 9.12) 9.11.1 If “Yes,” ask: “How long before (s)he died did ______stop being able to grasp?” ...... 1. Less than 12 hours ___ 2.12 hours or more ___

9.12 “At any time during the last month of the illness that led to death, did ______stop being able to respond to a voice?” ...... 1. Yes ___ 2. No ___ 8. Don’t know ___ (If “No” or “Don’t know,” go to 9.13) 9.12.1 If “Yes,” ask: “How long before (s)he died did ______stop being able to respond to a voice?” ...... 1. Less than 12 hours ___ 2.12 hours or more ___

9.13 “At any time during the last month of the illness that led to death, did _____ stop being able to follow movements with his/her eyes?” ...... 1. Yes ___ 2. No ___ 8. Don’t know ___ (If “No” or “Don’t know,” go to 9.14) 9.13.1 If “Yes,” ask: “How long before (s)he died did _____ stop being able to follow movements with his/her eyes?” ...... 1. Less than 12 hours ___ 2.12 hours or more ___

9.14 “Did _____ have a stiff neck during the last month of the illness that led to death?” ...... 1. Yes ___ (Demonstrate a stiff neck) 2. No ___ 8. Don’t know ___ 9.15 “Did _____ have a bulging fontanelle during the last month of the illness that led to death?” ...... 1. Yes ___ 2. No ___ 8. Don’t know ___

9.16 “During the last month of the illness that led to death, did _____ bleed into his/her skin or from any body opening?” ...... 1. Yes ___ 2. No ___ 8. Don’t know ___

9.17 “During the month before death, did _____ have a skin rash?” ...... 1. Yes ___ 2. No ___ 8. Don’t know ___ ANNEX A

66 Child’s Identification Number ______

9.17.A “During the month before death, did _____ have a measles rash?” ...... 1. Yes ___ 2. No ___ 8. Don’t know ___ (If “No” or “Don’t know” for 9.17 and 9.17.A, go to 9.18) 9.17.1 If “Yes, rash or measles rash,” ask: “Where was the rash?” ...... 1. Face ___ 2. Body ___ 3. Arms/legs ___ 8. Don’t know ___ 9.17.2 If “Yes, rash or measles rash,” ask: “How many days did the rash last?” ...... days ______

9.18 “Was _____ very thin during the month before (s)he died?” ...... 1.Yes ___ 2. No ___ 8. Don’t know ___

9.19 “Did _____ have swollen legs or feet during the month before (s)he died?” ...... 1.Yes ___ 2. No ___ 8. Don’t know ___

9.20 “Did _____ have “marasmus” (local term: ______) during the month before (s)he died?” ...... 1. Yes ___ 2. No ___ 8. Don’t know ___

9.21 “Did _____ have “kwashiorkor” (local term: ______) during the month before (s)he died?” ...... 1. Yes ___ 2. No ___ 8. Don’t know ___

9.22 “During the month before s(he) died, did _____ have pale palms?” (Show photo and/or explore local terms: ______, ______) ...... 1. Yes ___ 2. No ___ 8. Don’t know ___

GO TO SOCIAL AUTOPSY QUESTIONNAIRE ANNEX A

67

SOCIAL AUTOPSY FORM CHILD’S ID #: ______DATE: ___/___/___ SURVEYOR ID #: ______

INSTRUCTIONS TO SURVEYOR: 1) COMPLETE I.D. 2–4) REVIEW THE ILLNESS SYMPTOMS. 5–6) ASK ABOUT THE ACTIONS TAKEN FOR THE ILLNESS. COMPLETE ONE ROW FOR EACH ACTION. 7) CHECK FOR ERRORS.

2) Transfer the symptoms from the Medical Autopsy form to the symptoms box below. Then: 3) state: “Now I would like to review the symptoms of your child’s illness. First, let’s try to put them in the order that they occurred. You mentioned that the child had (read the symptoms). Which happened first? Which happened next?” 4) STATE: “Now for each symptom, I would like to know the day of the illness that the symptom started, how INSIDE-THE-HOME long it lasted, and the reason you think the child had the problem. 4A) What day did (symptom _) start? 4B) How many days did it last? 4C) Why do you think the child got (symptom _)?”

SYMPTOMS 1 2345 6789

DAY OF SYMPTOM

DURATION OF SYMPTOM

REASON FOR SYMPTOM

“Why did you think that (treatment) was a good thing to do?”

FIRST LAST 5) RECORD ACTION CODE & DAY OF ACTION, AND CHECK SYMPTOM BOXES. 5A)STATE: “Now, what was the first thing you did when you DAY OF DAY OF noticed that the child was ill?” 5B) “How many days had the child been ill when you (first) took this action?” [5C) “How many days had the child been # ACTION ACTION ACTION ill when you last took this action?”] 5D) “Which symptoms did (s)he have when you (first) did this?” 6A) If the action was in-home treatment, ask: 1

2 3

4

5 6

7

8

9 10 Annex B 69 ANNEX B 70 ANNEX B

6B) IF THE ACTION WAS AN OUTSIDE-THE-HOME TREATMENT, ASK:

OUTSIDE-THE-HOME INSIDE or OUTSIDE-THE-HOME 6C) IF THE CHILD WAS NOT SEEN BY A HEALTH AGENT, ASK:

“Why did you “What did the person you “What did this person suggest “Were you able to do (the first “Were you able to do (the “What prevented you from taking the child to A go there ?” saw do for the problem ?” that YOU do for the problem ?” thing) that this person second thing) that this person see a (health agent) at this time ?” C suggested ?” suggested ?” T I O 1= Y If “NO”, ask: “Why were 1= Y If “NO”, ask: “Why were you not able to follow the you not able to follow the N 2= N 2= N advice ?” advice ?” Nurse or nurse auxiliary Doctor or midwife

1

2

3

4

5

6

7

8

9

10 .MEDICALNOTES 3. “Doyor have any healthrecordsfrom 2. certificate “Was abirth 1. STATE: Surveyor's ProceduresManualexplainshowtocompletethisquestionnaire. theillnessthatledtodeath.during of theinterview. onoutside-the-homehealthcareprovided Itprovides moreinformation tothechild forInstructions surveyor: This questionnaireisadministeredaftertheSocialAutopsy, andisthelastpart Treatment andRecords Questionnaire birth and medical treatments.” medical and birth 3.1.1 __ __/__ __/__ __ 3.1.2. __ __/__ __/__ __ 3.1.2. __ __/__ __/__ __ 3.1.1 NumberoftheChild 3.1 3.A 2.1 Recordthedateof 1.2 “May Iseethecertificate 1.1 _____’s of have may you records any abort questions some you ask to like world I “Now d y d y (dd/myy) (dd/myy) (d d/myy) atnt ols oetonextlastnote prior the of Date tolastnote Dateofthenext last note Date ofthe The date of the last note last the of date The ask: “Yes”, If Child’s IdentificationNumber__ “May Iseethehealthrecords? issued?” The Treatment andRecords brh...... birth shat ad...... ’s healthcard ...... 1. Y ...... , please?” the child’s ill __/__ __ 3.1.3. __ __/__ __/______/__ __/__ __ 3.1.3. __ __/__ ...... 1...... 1. es”...... 1...... ness?” and Birth andDeathCertificate and Birth ...... 1. Yes ___ ...... (If “No” or “Don’t know”, go to 4) to go know”, “Don’t or “No” (If 2) to go know”, “Don’t or “No” (If (d/my) ______/___ 8. Don’tknow___ 8. Don’tknow___ (If “No”, go to 4) to go “No”, (If ___/___/___ 2. No___ 2. No___ 2. No___ 2. No___ Yes ___ Yes ___ es ___ Annex C 71 ANNEX C 72 ANNEX C 2...... 2. No ___ ...... 2 2.ANCcard(red)___ 3.2.1 3. Other(specify:______)___ .1 1. 3.2.1 3.2.1 3.2 22.No___ 2.No___ .2 1.___ Yes ... Dehydration 3.4.1 .1 3.4.1 3.4.1 2.Missing___ 3.4 ofthe 2.No___ .9 3.3.1 1. Yes______) 1. Yes___ .8 3.3.1 2.No___ .7 1. Yes___ Injury 3.3.1 2.No___ oranemia .6 3.3.1 .5 3.3.1 2.No___ .4 Fever 3.3.1 2.No___ problems .3 O 3.3.1 .2 Fast 3.3.1 .1 3.3.1 3.3.1 note 3.3 the Transcribe oto ii .1. Yes___ .. Control Visit Source ofthelastnote Diarrhea last note Observations ofthe Observations illness 1. Evolution Other (specify Malnutrition Rash Diarrhea last note Symptoms ofthe Symptoms The ther respiratory Record the source of the note the of source the Record Health Card(blue)___ rahn 1. Yes___ breathing ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ ...... 9. Missing___ 9. Missing___ Noted ___ 2. No___ 2. No___ 2. No___ Child’s IdentificationNumber__ 22.No___ 2.No___ .2 1.___ Yes ... Dehydration 3.4.2 .1 3.4.2 3.4.2 2.Missing___ ...... ofthe 2.No___ .9 3.3.2 ___ Yes 1. ______) .8 3.3.2 2.No___ .7 Injury 3.3.2 2.No___ oranemia .6 3.3.2 .5 3.3.2 2.No___ .4 Fever 3.3.2 2.No___ problems .3 O 3.3.2 .2 Fast 3.3.2 .1 3.3.2 2.No___ 3.3.2 .2 2.ANCcard(red)___ 3.2.2 3. Other(specify:______)___ .1 1. 3.2.2 3.2.2 Diarrhea Ob. nexttothelastnote the illness 1. ... Evolution Other (specify Malnutrition Rash Diarrhea next tolastnote Symptoms ofthe 1. Yes___ .. Control Visit last note Source ofthenextto ther respiratory Health Card(blue)___ rahn 1. Yes___ breathing ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ ...... 9. Missing___ 9. Missing___ Noted ___ 2. No___ 2. No___ 2. No___ 22.No___ 2.No___ .2 1.___ Yes ... Dehydration 3.4.3 .1 3.4.3 3.4.3 2.Missing___ ofthe 2.No___ .9 3.3.3 1. Yes______) .8 3.3.3 2.No___ .7 Injury 3.3.3 2.No___ oranemia .6 3.3.3 .5 3.3.3 2.No___ .4 Fever 3.3.3 2.No___ problems .3 O 3.3.3 .2 Fast 3.3.3 .1 3.3.3 2.No___ 3.3.3 .2 2.ANCcard(red)___ 3.2.3 3. Other(specify:______)___ .1 1. 3.2.3 3.2.3 Diarrhea the lastnote Ob. priortothenext illness 1. ... Evolution Other (specify Malnutrition Rash Diarrhea next tolastnote Sym. ofthepriorto 1. Yes___ .. Control Visit to lastnote Src. ofthepriortonext ther respiratory Health Card(blue)___ rahn 1. Yes___ breathing ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ ...... 9. Missing___ 9. Missing___ Noted ___ 2. No___ 2. No___ 2. No___ 1 rmdrt . 1. Yes___ ... ormoderate .14 Mal 3.4.1 2.No___ 2.No___ orlethargic .13 3.4.1 .12 3.4.1 2.No___ 2. No___ fontanelle .11 Bulging 3.4.1 .10 3.4.1 generalized .9 3.4.1 pustules 2.No___ .8 3.4.1 ___ ...... 7 RectalTemperature 3.4.1 .6 1. Yes___ rales Crepitant 2.No___ 3.4.1 indrawing .5 3.4.1 2. No ___ .4 Fast 3.4.1 stools .3 3.4.1 nosiu 1. Yes___ . Unconscious 1. Yes___ .. Convulsions 1...... Yes ___ Stiff neck Rash Many orsevereskin Lower chestwall 1. Yes___ ... Blood inthe nutrition severe rahn 1. Yes___ breathing .....1. Yes___ ...... (Missing = 99.9) = (Missing ....1. Yes___ ...... 1. Yes___ ...... 9. Missing___ 9. Missing___ 9. Missing___ 9. Missing___ 9. Missing___ 9. Missing___ 9. Missing___ 9. Missing___ 9. Missing___ 9. Missing___ 9. Missing___ ..1. Yes___ .... 2. No___ 2. No___ 2. No___ 2. No______. Child’s IdentificationNumber__ 1 rmdrt . 1. Yes___ ... ormoderate .14 Mal 3.4.2 1 2.No___ 1. Yes___ .... orlethargic .13 3.4.2 .12 3.4.2 2.No______...... 7 RectalTemperature. 3.4.2 .6 Crep 3.4.2 1 2.No___ fontanelle .11 Bulging 3.4.2 .10 3.4.2 generalized .9 3.4.2 2.No___ indrawing .5 3.4.2 .4 Fast 3.4.2 8pustules .8 3.4.2 1. Yes___ ...... stools .3 3.4.2 Unconscious 1. Yes___ .. Convulsions tf ek... 1...... Yes Stiff neck ___ Rash Lower chestwall Many orsevereskin Blood inthe nutrition severe rahn 1. Yes___ breathing tn ae 1. Yes___ itant rales (Missing = 99.9) = (Missing ....1. Yes___ ...... 1. Yes___ ...... 1. Yes___ ...... 9. Missing___ 9. Missing___ 9. Missing___ 9. Missing___ 9. Missing___ 9. Missing___ 9. Missing___ 9. Missing___ 9. Missing___ 9. Missing___ 9. Missing___ ..1. Yes___ .... 2. No___ 2. No___ 2. No___ 2. No___ 2. No___ 2. No___ 2. No______. 62.No______...... 7 RectalTemperature 3.4.3 .6 1. Yes___ rales Crepitant 3.4.3 42.No___ indrawing .5 3.4.3 .4 Fast 3.4.3 1. Yes___ ...... stools .3 3.4.3 .. Mal 3.4.3 2.No___ 1. Yes___ .... orlethargic .13 3.4.3 .12 3.4.3 2.No___ fontanelle .11 Bulging 3.4.3 .10 3.4.3 generalized .9 3.4.3 1 rmdrt . 1. Yes___ ... ormoderate .14 pustules .8 3.4.3 Lower chestwall Blood inthe Unconscious 1. Yes___ .. Convulsions 1...... Yes ___ Stiff neck Rash Many orsevereskin nutrition severe rahn 1. Yes___ breathing (Missing = 99.9) = (Missing ....1. Yes___ ...... 1. Yes___ ...... 1. Yes___ ...... 9. Missing___ 9. Missing___ 9. Missing___ 9. Missing___ 9. Missing___ 9. Missing___ 9. Missing___ 9. Missing___ 9. Missing___ 9. Missing___ 9. Missing___ ..1. Yes___ .... 2. No___ 2. No___ 2. No___ 2. No___ 2. No___ 2. No___ 2. No______. 73 ANNEX C 74 ANNEX C 3.5 2 2.No___ .20 1. Yes___ Malformation. 3.4.1 extending .19 3.4.1 2.No___ Injury 3.4.1 .16 P 3.4.1 1. Yes___ ...... twofeet .15 3.4.1 52.No___ 2.No___ orborn .6 2.No___ Low 3.5.1 .5 2.No___ Injury 3.5.1 .4 2.No___ S 3.5.1 .3 3.5.1 .2 Pneumonia 3.5.1 .1 3.5.1 3.5.1 2.No___ capacitytobreastfeed .18 3.4.1 .17 Use this section for children who were one month old or more before dying. If the child was child the If dying. before more or old month one were who children for section this Use more than one month at the time of death use section 3.6. section use death of time the at month one than more osi 2. No ___ skin to Umbilical redness Edema of premature 1...... Meningitis Diarrhea last note Diagnosis ofthe Diagnosis Neonatal 1. orcry...... Absence ofweak l am ..1. Yes___ .... ale palms piii .. 1. Yes___ ..... epticimia birthweight ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ ...... 9. Missing___ 9. Missing___ 9. Missing___ 9. Missing___ 9. Missing___ 9. Missing___ ..1. Yes___ .... 2. No___ 2. No___ 2. No___ Yes___ Yes ___ Child’s IdentificationNumber__ 2 2.No___ .20 1. Yes___ Malformation. 3.4.2 1 extending .19 3.4.2 2.No___ Injury 3.4.2 .16 P 3.4.2 1. Yes___ ...... twofeet .15 3.4.2 52.No___ 2.No___ orborn .6 2.No___ Low 3.5.2 .5 2.No___ Injury 3.5.2 .4 2.No___ S 3.5.2 .3 3.5.2 .2 Pneumonia 3.5.2 .1 3.5.2 3.5.2 2.No___ capacitytobreastfeed .18 3.4.2 .17 osi 2. No ___ skin to Umbilical redness Edema of premature 1...... Meningitis Diarrhea D. nexttothelastnote 1...... or cry Absence ofweak l am ..1. Yes___ .... ale palms piii .. 1. Yes___ ..... epticimia birthweight ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ ...... 9. Missing___ ...1. Yes___ ...... 1. Yes___ ...... 9. Missing___ 9. Missing___ 9. Missing___ 9. Missing___ 9. Missing___ ..1. Yes___ .... 2. No___ 2. No___ 2. No___ Yes___ Yes ___ 2 2.No___ .20 3.4.3 extending .19 3.4.3 2.No___ capacitytobreastfeed .18 2.No___ 3.4.3 .17 Injury 3.4.3 .16 P 3.4.3 1. Yes___ ...... twofeet .15 3.4.3 52.No___ 2.No___ orborn .6 2.No___ Low 3.5.3 .5 2.No___ Injury 3.5.3 .4 2.No___ S 3.5.3 .3 3.5.3 .2 Pneumonia 3.5.3 .1 3.5.3 3.5.3 osi 2. No ___ . 1. Yes ___ Malformation skin to Umbilical redness 1...... or cry Absence ofweak Edema of premature 1...... Meningitis Diarrhea the lastnote D. priortothenext l am ..1. Yes___ .... ale palms piii .. 1. Yes___ ..... epticimia birthweight ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ ...... 9. Missing___ 9. Missing___ 9. Missing___ 9. Missing___ 9. Missing___ 9. Missing___ ..1. Yes___ .... 2. No___ 2. No___ 2. No___ Yes___ Yes ___ 1 2.No___ 2.No______No (specify______)2. .11 2.No___ O 3.6.1 .10 2.No___ Injury 3.6.1 .9 Anemia 3.6.1 .8 3.6.1 2.No___ .7 3.6.1 2.No___ Dengue .6 2.No___ Hem 3.6.1 .5 2.No___ M 3.6.1 .4 2.No___ 3.6.1 .3 Measles 3.6.1 .2 Pneumonia 3.6.1 .1 3.6.1 3.6.1 2.No___ 3.6 2.No___ 2.No___ (specify____) .11 O 3.5.1 .10 2. No___ 3.5.1 .9 Trauma Asphyxia 3.5.1 .8 Birth 3.5.1 tetanus .7 3.5.1 Use this section for children who were one month old or more before dying. If the child the If dying. before more or old month one were who children for section this Use was less than one month at the time of death use section 3.5. section use death of time the at month one than less was antiin..1. Yes___ ... Malnutrition 1. Yes___ .... Septecimia 1...... Meningitis ... Diarrhea note Diagnosis ofthelast Diagnosis Post-neonatal 1. Yes___ . Malformation Neonatal ther ther alaria orragic fever ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ .... 2. No___ 2. No___ Yes ___ Child’s IdentificationNumber__ 52.No___ Dengue .6 Hem 3.6.2 .5 1 2.No___ 2.No______No 2. (specify_____) .11 2.No___ O 3.6.2 .10 2.No___ Injury 3.6.2 .9 Anemia 3.6.2 .8 3.6.2 .7 3.6.2 42.No___ 2.No___ 2.No___ M 3.6.2 .4 2.No___ 3.6.2 .3 Measles 3.6.2 .2 Pneumonia 3.6.2 .1 3.6.2 3.6.2 2.No___ 2.No______No 2. (specify_____) .11 O 3.5.2 .10 3.5.2 .9 Trauma 3.5.2 1. Yes___ ...... Asphyxia .8 Birth 3.5.2 tetanus .7 3.5.2 antiin..1.___ Yes ... Malnutrition 1. Yes___ .... Septecimia eigts...1...... Meningitis Diarrhea D. nexttothelastnote 1.___ Yes . Malformation Neonatal ther ther alaria orragic fever ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ .... 2. No___ 2. No___ 2. No___ Yes ___ 1 2.No___ 2.No______No (specify______)2. .11 2.No___ O 3.6.3 2.No___ .10 Injury 3.6.3 .9 Anemia 3.6.3 .8 2.No___ 3.6.3 .7 2.No___ 3.6.3 Dengue 2.No___ .6 Hem 3.6.3 2.No___ .5 M 3.6.3 2.No___ .4 3.6.3 .3 Measles 3.6.3 .2 Pneumonia 3.6.3 .1 3.6.3 3.6.3 8Apyi ....1...... Asphyxia .8 Birth 3.5.3 tetanus .7 3.5.3 1 2.No___ 2.No___ O 3.5.3 .10 3.5.3 .9 Trauma 3.5.3 1 seiy___ 2. No___ (specify _____) .11 Malnutrition 1...... Septecimia 1...... Meningitis Diarrhea the lastnote D. priortothenext Neonatal afrain. 1. Yes___ .. Malformation ther ther alaria orragic fever ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ .... 2. No___ 2. No___ 2. No___ Yes___ Yes ___ Yes ___ 75 ANNEX C 76 ANNEX D 22.No___ 2.No___ 1. Yes___ ...... Injections .3 3.7.1 .2 ORS 3.7.1 .1 IV 3.7.1 3.7.1 3.7 1 2.No___ Treatment .12 O 3.7.1 .11 3.7.1 therapy .10 Nutritional 3.7.1 1. Yes___ .... Medication .9 O 3.7.1 1. Yes___ .... convulsant .8 Anti- 3.7.1 1...... 7 Tetanus Immunoglobulin 3.7.1 antimalarial .6 Oral 3.7.1 1. Yes___ ...... Injections .5 3.7.1 1. Yes___ ..... antibiotics .4 Oral 3.7.1 Antibiotic note Treatments ofthelast Surgery 2.No___ (specify ____) Antimalarial Treatments seiy___)2. No ______) (specify ther ther ouin . 1. Yes___ ... solutions ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ .... 2. No___ 2. No___ 2. No___ 2. No___ 2. No___ 2. No___ 2. No___ Yes ___ Child’s IdentificationNumber__ 22.No___ 2.No___ 1. Yes___ ...... Injections .3 3.7.2 .2 ORS 3.7.2 .1 IV 3.7.2 3.7.2 1 2.No___ Treatment .12 O 3.7.2 .11 3.7.2 therapy .10 Nutritional 3.7.2 1. Yes___ .... Medication .9 O 3.7.2 1. Yes___ .... convulsant .8 Anti- 3.7.2 1...... 7 Tetanus Immunoglobulin 3.7.2 antimalarial .6 Oral 3.7.2 1. Yes___ ...... Injections .5 A 3.7.2 1. Yes___ ..... antibiotics .4 Oral 3.7.2 Antibiotic the lastnote Tr. ofthenext to seiy___)2. No ______) (specify Surgery 2.No___ (specify ____) ntimalarial ther ther ouin . 1. Yes___ ... solutions ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ .... 2. No___ 2. No___ 2. No___ 2. No___ 2. No___ 2. No___ 2. No___ Yes ___ 1 2.No___ Treatment .12 O 3.7.3 .11 3.7.3 therapy .10 Nutritional 3.7.3 1. Yes___ .... Medication .9 O 3.7.3 1. Yes___ .... convulsant .8 Anti- 3.7.3 1...... 7 Tetanus Immunoglobulin 3.7.3 6antimalarial .6 Oral 3.7.3 1. Yes___ ...... Injections .5 3.7.3 1. Yes___ ..... antibiotics 2.No___ .4 Oral 3.7.3 2.No___ 1. Yes___ ...... Injections .3 3.7.3 .2 ORS 3.7.3 .1 IV 3.7.3 3.7.3 seiy___ 2. No ______) (specify Surgery 2.No___ (specify ____) Antimalarial Antibiotic the lastnote Tr. priortothenext to ther ther ouin . 1. Yes___ ... solutions ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ .... 2. No___ 2. No___ 2. No___ 2. No___ 2. No___ 2. No___ 2. No___ Yes ___ .Recordthecausesofdeathanddateonbackthisform 5. “Was issued?” adeathcertificate 4. THANK THERESPONDENTFORHER/HISHELPANDTIME . “May Iseethedeathcertifi 4.1 Child’s IdentificationNumber__ END OFINTERVIEW cate?”...... 1. Y ...... (If “No”or“Don’tknow”,gotoend) 8. Don’tknow___ (If “No”,gotoend) 1. Yes ___ 2. No___ 2. No___ es ___ 77 ANNEX D

Annex D Medical Records Abstraction Form

Child’s Identification Number ______

Instructions to abstractor: Section 1 will be complete when the mortality project logistics coordinator gives you this form. Use this information to help you locate the health facility where the child received care and the record that you must abstract. Complete Sections 2 and 3 by abstracting the record.

Section 1: Background information from interview

1.1 Name of child______1.1.A Child’s health card # ...... ___/___/___

1.2 Sex of child...... 1. Male ___ 2. Female ___

1.3 Child's birth date ...... ______/______/______...... ( d d / m m / y y )

1.4 Child's age (in completed days or months) at time of death: ...... days/months ______(Circle the correct word. Use “days” if <28 days.)

1.5 Date of the death ...... ______/______/______( d d / m m / y y )

1.6 Facility name and address ______

______

1.7 Facility type ...... 1. Hospital ___ 2. Health center ___ 3. Health post or dispensary ___ 4. Private office ___ 5. Other (specify ______) ___

Section 2: Information about the record abstraction

2.1 Abstractor's code number ____

2.2 Date of record abstraction ______/______/______

Date form checked by project representative ______/______/______

Date entered in computer ______/______/______ANNEX D

79 80 ANNEX D . aecidse ...... Datechildseen 3.2 Type ofproviderwho 3.1 Section 3:Medicalrecordabstraction that youneedtoabstract,beforeyourarrival. The directorshouldbeexpecting you. You shouldhave informed himorherofyour visitandtherecord(s) Instructions toabstractor:Introduceyourselfthefacilitydirectorandexplainpurposeofyourvisit. . Reasonsforvisit(chiefcomplaints) 3.4 Informationsource 3.3 .. Fast 3.4.4 3.4.3 particular a 3.4.2 have not did caregiver the If 3.4.1 reason. each for “No” or “Yes” (Check 3.4.11 M 3.4.10 3.4.9 3.4.8 Fever 3.4.7 Otherrespiratory 3.4.6 3.4.5 complaint, then mark “2. No.”) “2. mark then complaint, Cough Blood inthestool Diarrhea Injury Rash Convulsions Difficult breathing(dyspnea) alnutrition oranemia breathing ...... 1...... 1...... 1. R ...... 1...... 1...... 1...... 1...... 1. Child’s IdentificationNumber__ ...... 1...... 1. saw child ...... 1. Physician___ ...... 1. saw child ...... 1...... 1. problem (specify______) ...... 1...... 1...... 1. Yes___ ...... 1...... 1. Yes___ ...... 1. 5. Other(specify______)___ 3. Other(specify______)___ egister ordischargelogbook___ 4. Technical healthagent___ ( d/my) ______/___ 2. Medicalrecord___ ...... 1. Yes___ ...... 1. 3. Healthaid___ 2. Midwife___ 2. No___ 2. No___ 2. No___ 2. No___ 2. No___ 2. No___ 2. No___ 2. No___ 2. No___ 2. No___ 2. No___ Yes ___ Yes ___ Yes ___ Yes ___ Yes ___ Yes ___ Yes ___ Yes ___ . Medicalexamfindings 3.5 3.4.A ..3Newbornproblem(specify______) 3.4.13 Other(specify______) 3.4.12 3.5.1 Evolution oftheillness 22.Some___ 1. .. dayonheaviest .4 2. No ___ 3.5.1 diarrheaobserved .3 3.5.1 Dehydration .2 3.5.1 loosestoolsobserved .1 3.5.1 Diarrhea examfindings: If liquid, watery or loose stools or any dehydration observed, dehydration any or stools loose or watery liquid, If then ask 3.5.1.3–3.5.5.6. ask then tososre e .. lo bevd... 1. Yes___ ...... 3.5.5Bloodobserved Stools observedper Number ofdays iud aeyo 1. Yes___ Liquid, wateryor Child’s IdentificationNumber__ (If “No,” or “Missing” to 3.5.1.1 3.5.1.1 to “Missing” or “No,” (If ...... 1...... (Missing = 99) = (Missing 99) = (Missing (If the child was >1 month old at death, then go to 3.5) to go then death, at old month >1 was child the (If ...... ______.5 2. No ___ No 2. in .6 ______.5 ______.. V 3.5.1 and 3.5..1.2 then go to 3.5.2) to go then 3.5..1.2 and mtn bevd.1. Yes___ . omiting observed tos2. No ___ stools ...... 1...... 1...... 1. Yes___ ...... 1. 9. Missing___ 9. Missing___ 9. Missing___ 9. Missing___ 3. None___ Severe ___ 2. Missing___ Present ___ 2. No___ 2. No___ Yes ___ 81 ANNEX D 82 ANNEX D 3.5.2 3.5.3 Respiratory examfindings: Fever orrashexamfindings: 52 o__.0 rfo pnn 2. No ___ .10orfromopening 2. No ___ 2. No ___ .8(observed) 2. No ___ 2. No ___ .5 Red 3.5.3 3.5.3 .7 .3 1. ... Generalizedrash 3.5.4 2. No ___ .2 skinpustules 3.5.3 .1 Rectal 3.5.3 .4 2. No ___ .9 obtunded 2. No ___ No 2. obtunded .9 ___ No 2. 3.5.3 .4 .1 3.5.2 Cough Respiratory 3.5.2. 32 o__. 2.No___ 2. No ___ 2.No___ 2. No ___ .8 2.No___ .9 .5 retractions .7 3.5.2 2. No ___ 2.No___ indrawing wall .4 3.5.2 .3 F 3.5.2 .2 ayo eee...1. Yes___ ..... Many orsevere Nasal discharge C ...... temp. rate necsa ...... 1. Yes___ ...... Intercostal 1. Yes___ ...... Fever 3.5.2 1. Yes___ ...... chest Lower ast breathing ...... eyes Child’s IdentificationNumber__ ...... 1 e _ 3. 1. Yes___ ...... 1. Yes___ ...... (Missing = 99.9) = (Missing (Missing = 999) = (Missing ... .Ys__352Nslfaig...... 1. Yes___ ...... 3.5.2Nasalflaring 1. Yes___ ...... Msig__9.Missing___ 9.Missing___ 9. Missing___ 9.Missing___ 9. Missing___ 9. Missing___ .Msig__9.Missing___ 9. Missing___ .Msig__9.Missing___ 9.Missing___ 9. Missing___ 9.Missing___ 9. Missing___ 9. Missing___ 9. Missing___ ..1. Yes___ .... 0 ______.___ .6 2. No ___ No 2. .6 ______.______62.No___ .6 ___ Yes ___ 3.5.3 3.5.3 3.5.3 3.5.3 3.5.6 Crepitantrales 5.2 Grunting Convulsions 1. Yes___ .. Bulging fontanelle nosiu r... 1...... Unconscious or 1...... Stiff neck leigit kn. 1. Yes___ .. Bleeding intoskin ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ ...... 9. Missing___ 9. Missing___ Yes___ Yes___ 3.5.5 N 3.5.4 Injury examffindings: utrition examfindings: 12 o__. 2. Drowning ___ .3 ___ No 2. .1 .. Injury 3.5.5 22 ilnewr__6.Other (specify______)___ 2. Violence/war ___ .2 3.5.5 3wsig__. 2.No___ .6 oraledema wasting___ .4 Generalizedor 3.5.4 .3 Appearance 3.5.4 .2 3.5.4 .1 3.5.4 (If “No” or “Missing,” go to 3.5.6) to go “Missing,” or “No” (If icmtne .Fl _ 5.Burn___ 1.Fall___ Circumstances egt(m ...... Height (cm) Weight (kg) 6. Motorvehicleaccident___ ...... 1...... Child’s IdentificationNumber__ 7. Otheraccident___ 5. Intentionalhits___ 3. Fire weapon ___ 9. 9. 3. Fireweapon___ ...... 1. Yes___ ...... 4. Steelblade___ 4. Overweight___ ...... 1...... 8. Birth injury ___ 8. injury Birth (Missing = 99.9) = (Missing (Missing = 999) = (Missing .Msig__3. 9. Missing___ 9. Missing___ .Msig__2. No ___ 9. Missing___ 9. Missing___ .Nra _ .. Pale 3.5.4 3. Normal______E 3.5.4 ______.___ .Ti _ 9.Missing___ 2. Thin ___ 2. No___ Yes ___ Severe 3.5.5 5 ohfe 2. No ___ .5 bothfeet 7conjunctivae .7 P 3.5.4 nuytp ....1...... Trauma ___ Injury type (edema) 9. 9. (edema) l am...... 1. Yes___ ale palms...... cs li f... 1. Yes ...... ___ xcess fluidof 4. Animalbiteorsting___ .....1. Yes___ ...... Poisoning ___ 9. Missing___ Missing ___ Missing ___ 83 ANNEX D 84 ANNEX D 3.5.6 . Examensdelaboratoire 3.6 Newborn examfindings: 3.6.1 3.6) to go then death, at old month >1 was child the (If Complete bloodcount 32 ek__. 2. No ___ 2. Body ___ .8malformation(s) 2. No ___ .7 2. Weak___ 2. No ___ .4 .6skinpustules 2. Weak ___ .3 Cry 3.5.6 .2 3.5 .4 __ __ .3 3.6.1 WBC .2 3.5.6 2. No ___ .5extendingtoskin 3.5.6 .1 consciousness 3.5.6 12.Notordered___ Hgb 3.6.1 1.Completed___ .1 CBC 3.6.1 ugn otnle. 1. .. Bulging fontanelle 1...... Suckle 1.Unconscious___ . Level of (Si “Not ordered,” goto3.6.2) ...... 1...... ___ ...... Child’s IdentificationNumber__ 3. Irritable/agitated 2. Lethargic______/m .. ypoye ___% 3.6.1 Lymphocytes __ /mm3 .Msig__9. Missing ___ 9. Missing___ 9. Missing___ 9. Missing___ 3. Normal ___ 9. 9. 9. 3. Normal___ 3. Normal___ 4. Normal______.___ g/dl None ___ oe__3.5.6 None ___ e _ 3.5.6 Yes ___ _ discharge ___ 3.5.6 3.5.6 .. oy ...... 3.6.1 Polys (If “No” or “Missing,” go to 3.6) to go “Missing,” or “No” (If Malformation oaino...... 1. Location of...... 1. Yes___ Many orsevere...... or purulent 9. 9. or purulent 1. Yes___ .. Umbilical redness allowed) responses (Multiple 5. Internalorgan___ 3. Arms/hands___ .....1. Yes___ ...... 4. Legs/feet___ 9. Missing___ Missing ___ Missing ___ Missing ______% Head ___ 3.6.3 Lumbarpuncture 3.6.2 Thick smearforparasites 22.Some___ 2.Notordered___ .2 3.6.3 .1 3.6.3 22 oe__. ___/mm3 .4 2.Some___ T 3.6.1 1.Numerous___ 2.Notcompleted___ .2 Bacteria 3.6.2 .1 LP 3.6.2 3morphology .3 3.6.2 Plasmodia Thick smear Bacterial 3.6.2 Polys ______% ___ Polys 3.6.2 Bacterial (Si “Not completed,” goto3.6.3) ...... 1...... Child’s IdentificationNumber__ ...... 1...... ______.5 ______...... 1...... Completed ___ 4. None___ 3. Rare___ .. ypoye ______% .6 3.6.2 Lymphocytes otal whitecells (Si “Not ordered,” go to 3.7) to go ordered,” “Not (Si Completed ___ Numerous ___ 4. None___ 3. Rare___ 85 ANNEX D 86 ANNEX D (Check “Yes” or “No” for each diagnosis. If a particular diagnosis is not recorded, then mark then recorded, not is diagnosis particular a If diagnosis. each for “No” or “Yes” Diagnoses (Check 3.7 “2. No.”) “2. 52 o__.1 seiy_____ 2. No ___ .11(specify______) 2. No ___ 2. No ___ .11 (specify ______) 2. No ___ .6 hemorrhagicfever 3.7.2 .5 32 o__. 2.No___ .9 2.No___ 2. No ___ .7noknown focus 2. No ___ 3.7.2 .3 2.No___ Pneumonia 3.7.2 2.No___ 2. No ___ .1 .11(specify______) 3.7.2 2. No ___ 2. No ___ 2.No___ 2. No ___ .12 (specify ______) 3.7.2 Postneonatal diagnoses. 2. No ___ .9 2.No___ .6 prematurity .8 w birth Low 3.7.1 2.No___ .10 .5 .7 Injury 2. No ___ 3.7.1 2.No___ .4 noknownfocus 3.7.1 .3 3.7.1 .2 Pneumonia 3.7.1 .1 3.7.1 3.7.1 42 o__.02.No___ 2.No___ .10 2.No___ .8 2.No___ M 3.7.2 .4 Measles 3.7.2 .2 month old at death. If the child was >1 month old at death, then go to go then death, at old month >1 was child the If death. at old month month old at death. at old month section 3.7.2 section Dengue eigts...... 1. Y ...... Meningitis Diarrhea 1. Yes___ Septicemia with..... 1. Yes___ ...... Meningitis Diarrhea Neonatal diagnoses alaria ...... Ys__371Ohr...... 1. Yes___ ...... Other 3.7.1 1. Yes___ ...... Child’s IdentificationNumber__ ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ ...... ih/..1. Yes___ ... eight/ ...... 1. Yes___ ...... 1. Yes___ ...... Use this section for children who were <1 were who children for section this Use s__3.7.2 Injury es ___ Use this section for children who were >1 were who children for section this Use .. O 3.7.1 O 3.7.2 3.7.2 3.7.1 trauma Birth 3.7.1 3.7.1 .. Anemia 3.7.2 3.7.2 O 3.7.1 Birth 3.7.1 etcmawt .. 1. Yes___ ..... Septicemia with Malformation 1. Yes___ ... Neonatal tetanus Malnutrition ther ther ther shxa....1. Yes___ ...... asphyxia ...... 1...... 1...... 1...... 1...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ ...... Yes ___ Yes ___ Yes ___ Yes ___ . Treatments andgiven prescribed, orpurchased 3.8 (Mark “Yes” or “No” for each treatment prescribed. If a particular prescription was not was prescription particular a If prescribed. treatment each for “No” or “Yes” (Mark recorded, then mark “2. No” and go to the next treatment. For each treatment that was that treatment each For treatment. next the to go and No” “2. mark then recorded, prescribed, mark whether it was given to the child or purchased at the facility. Mark: facility. the at purchased or child the to given was it whether mark prescribed, “8. Missing” if this information is not recorded.) not is information this if Missing” “8. . neto niaail3.8 .5.A 3.8 1. Yes___ prescribed Injectionantimalarial .5 prescribed 3.8 .11 ___ No 2. .4.A 1. Y prescribed Oralantibiotics .4 3.8 prescribed .10 ___ No 2. .3.A prescribed 3.8 prescribed .9 .3 Injectionantibiotics1. ___ No Y 2. 3.8 .2.A 3.8 ORSprescribed .2 3.8 Anticonvulsant 3.8 .1.A 3.8 prescribed Intravenousfluids .1 3.8 3.8 If “Yes,” mark (If “No,” go to 3.8.12) to go “No,” (If purchased given/ whether mark “Yes,” If 3.8.11) to go “No,” (If given/ whether mark “Yes,” If 3.8.10) to go “No,” (If given/ whether mark “Yes,” If given/ whether mark “Yes,” If purchased given/ whether mark “Yes,” If purchased purchased purchased ...... 9 isn _ 9.Missing___ 9.Missing ___ ...... Child’s IdentificationNumber__ (If “No,” go to 3.8.5) to go “No,” (If 3.8.4) to go “No,” (If 3.8.9) to go 3.8.3) “No,” to (If go “No,” (If 3.8.2) to go “No,” (If (If “No,” go to 3.8.6) to go “No,” (If ...... Ys__.22. No ___ .12 1. Yes___ ...... 8 1. Yes___ ...... 9. Missing___ 9. Missing___ 9.Missing___ 9. Missing___ 9. Missing___ ...... 1. Yes ...... Ys__.8.A 1. Yes___ .Ys__.12.A 1. Yes___ 3.8 1. Yes___ 3.8 1. Yes___ 3.8 1. Yes___ 2. No___ 2. No___ 2. No___ .11.A 2. No___ 1. Yes___ whethergiven/ .10.A 2. No___ .9.A 2. No ______No 2. (specify ______) ___ No 2. s__38Nutrition therapy 3.8 ___ es 3.8 es ___ _ . Othermedicine 3.8 ___ 3.8 3.8 ugr ...... 1. Yes___ ...... Surgery purchased given/ whether mark “Yes,” If purchased given/ whether mark "Yes," If purchased given/ whether mark “Yes,” If ___ No 2. purchased mark “Yes,” If ___ No (specify ______)2. Other medicine purchased given/ whether mark “Yes,” If ___ No 2. (specify ______) prescribed (If “No,” go to 3.8.13) to go “No,” (If ...... 1. Yes___ ...... 1. Yes___ ...... 1. Yes___ ...... 9. Missing___ 9. Missing___ 9. Missing___ ...... 1. Yes___ 1. Yes___ 1. Yes___ 1. Yes___ 2. No___ 2. No___ 2. No___ 2. No___ 2. No___ 87 ANNEX D 88 ANNEX D .1Instructionsforhomecare 3.11 Disposition 3.10 Reasonfor 3.9.B Reasonfor 3.9.A (Complete only if 3.10 = “Sent home”) “Sent = 3.10 if only (Complete number) treatment in (Write prescribed butnotgiven/purchased number) treatment in (Write prescribed butnotgiven/purchased ______7 goui rsrbd2. No ___ .7 globulinprescribed 3.8 Tetanusimm .7.A 3.8 prescribed .13 ___ No 2. .6.A 3.8 prescribed Oralantimalarial .6 3.8 (treatment ______)being (treatment ______)being ...... 1.Deadon ...... 3. ___ Treatment never . available atfacility/to bepurchasedby family outside 3. ___Treatment never available atfacility/to bepurchasedby family outside whether given/ whether mark “Yes,” If purchased given/ whether mark “Yes,” If purchased Child’s IdentificationNumber__ (If “No,” go to 3.8.8) to go “No,” (If 3.8.7) to go “No,” (If n-....1. Yes___ ...... uno- .Msig__9.Missing___ 9. Missing___ 9. Missing___ ...... 1. Yes ___ 3.8 Other treatment Other 3.8 1. Yes___ ...... Tetettmoaiyoto tc tfclt ___ 1. . Treatment outofstock facility temporarily at ...... ___ 1. . Treatment outofstock facility temporarily at ...... 1. Yes___ whether .13.A 1. Yes___ .Ohr(pcf:______. 4. Other(specify:______) ___ 4. Other(specify:______) 2. No______No 2. purchased ___ No 2. .Ohr(pcf ______).___ . 5. Other(specify______) (If “Sent home,” go to 3.11; otherwise, go to end) to go otherwise, 3.11; to go home,” “Sent (If ria tfclt rde eoebigamte ___ arrival atfacilityordiedbeforebeingadmitted 2. Treatment available atfacility butfamily 2. Treatment available atfacility butfamily .Rfre oaohrhat aiiy.___ . 3. Referredtoanotherhealthfacility 3.8 If “Yes,” mark “Yes,” If ___ No 2. (specify ______) .Amte ofclt ___ . 2. Admittedtofacility given/ ol o fodcs ___ . could notaffordcost ___ could notaffordcost (If “No,” go to 3.8.A) to go “No,” (If ...... 1. Yes___ ...... 1. Yes___ ...... Sn oe___ 4. Senthome ___ . 8. Don'tknow ___ 8. Don'tknow Annex E Scoring Criteria Used by the Expert Panel to Determine “Quality of Care”

I. Signs mentioned by the mother ...... 5 ■ Without signs 0 ■ With signs 3 ■ Evolution 2

II. Observations ...... 5 ■ Without observations 0 ■ Temperature taken 0,5 ■ Weight and height recorded 1 ■ Evaluation 2 ■ Auscultation 0,5 ■ Examination 1

III. Diagnosis ...... 5

IV. Treatment ...... 5 ■ No treatment 0 ■ No “standard” treatment 1 ■ “Standard” treatment 4

V. Follow up ...... 5 ■ Not following the established therapeutic guidelines 0 ■ Following the established guidelines 5

VI. Recommendations...... 5 ■ No recommendations given 0 ■ Recommendations given to caretaker 5

Scale used to define quality of care: Good quality care: 25–30 Average quality care: 15–24 Poor quality care: Less than 14 ANNEX E

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