Assessing the Causes of Under-Five Mortality in the Albert Schweitzer Hospital Service Area of Rural Haiti

Investigación original / Original research Assessing the causes of under-five mortality in the Albert Schweitzer Hospital service area of rural Haiti Henry B. Perry,1 Allen G. Ross,2 and Facile Fernand 3 Suggested citation Perry HB, Ross AG, Fernand F. Assessing the causes of under-five mortality in the Albert Schweitzer Hospital service area of rural Haiti. Rev Panam Salud Publica. 2005;18(3):178–86. ABSTRACT Objectives. Limited information is available regarding the causes of under-five mortality in nearly all of the countries in which mortality is the highest. The purpose of this study was to use a standard computerized protocol for defining the leading causes of death among children in a high-mortality rural population of Haiti and to highlight the need for similar studies else- where in Haiti and throughout the high-mortality areas of Latin America and the Caribbean. Methods. In 2001 a standardized, closed-ended verbal autopsy questionnaire endorsed by the World Health Organization was administered to a representative, population-based sample of the mothers or other caregivers of 97 children who had died before reaching 5 years of age between 1995 and 1999 in the service area of the Albert Schweitzer Hospital, which is located in the rural Artibonite Valley of Haiti. With the data from the questionnaires we used a computerized algorithm to generate diagnoses of the cause of death; the algorithm made it possible to have more than one cause of death. Results. Acute lower respiratory infection (ALRI) was the leading diagnosis, present in 45% of all under-five deaths, followed by enteric diseases, present in 21% of deaths. Neonatal tetanus, preterm birth, and other early neonatal causes unassociated with ALRI or diarrhea were present in 41% of the neonatal deaths. Among children 1–59 months of age, ALRI was present in 51% of the deaths, and enteric diseases in 30%. Deaths were concentrated during the first few months of life, with 35% occurring during the first month. Among the neonatal deaths, 27% occurred on the first day of life, and 80% occurred during the first 10 days of life. Conclusions. In the Albert Schweitzer Hospital program area—and presumably in other areas of Haiti as well—priority needs to be given to the prevention of and the early, effective treatment of ALRI, diarrhea, and early neonatal conditions. This study points to the need for more, similar standardized assessments to guide local, regional, and national programs. Key words Cause of death, data collection, autopsy, infant mortality, child mortality, child health services, Haiti. 1 Hôpital Albert Schweitzer, Deschapelles, Haiti There is a general recognition of the sample of the population are function- (now with Future Generations, Franklin, West Vir- importance of accurate information re- ing in only a few of the developing ginia, United States of America). Send correspon- dence to: Henry Perry, Future Generations, HC 73 garding cause of death among children countries that account for an over- Box 100, Franklin, West Virginia 26807, United in the developing nations of the world. whelming proportion of all the child States of America; e-mail: [email protected]; fax: 304-358-3008. Nevertheless, accurate vital events reg- deaths worldwide (1, 2). Just 42 nations 2 European College of Medicine, Rotherhithe, Lon- istration systems for the entire popula- with the largest numbers of deaths ac- don, United Kingdom. 3 Hôpital Albert Schweitzer, Deschapelles, Haiti. tion or even a small representative count for 90% of all the child deaths 178 Rev Panam Salud Publica/Pan Am J Public Health 18(3), 2005 Perry et al. • Assessing causes of under-five mortality in rural Haiti Original research worldwide. However, among those 42 FIGURE 1. Map of Haiti showing the location of Albert Schweitzer Hospital countries, only Mexico records the cause for more than 95% of the deaths (2). We are aware of only three pub- lished studies in English on the causes of death among children under 5 years Cap-Haïtien of age in high-mortality countries in the Western Hemisphere (1, 3, 4). Clearly, vital information on the causes Gonaïves of death in areas of high under-five mortality in the Americas is lacking. Reducing under-five mortality con- tinues to be a high priority through- Saint-Marc out the developing world, given that Albert 10.8 million children die annually Schweitzer from preventable causes (2). Reliable Hospital data to guide health policies and to Jérémie improve prevention and treatment strategies are needed, particularly in those countries with the highest rates Port-au-Prince of under-five mortality (2, 5). Unfortu- Les Cayes nately, these countries have the weak- est vital statistics and health information systems. Further complicating this picture is the fact that in studies that have used a verbal autopsy methodology to assess causes of child death, standardized approaches for approximately 250 000 people (7, 8). that had occurred between 1995 and measuring the causes of death have ASH is one of the few programs in the 1999. In 2001 we carried out a follow-up rarely been used (1). world that has documented an impact survey with the households of the fam- Haiti has the highest under-five on under-five mortality in its service ilies of these 144 children in order to col- mortality in the Western Hemisphere, area (9), and its system of health and lect information on the cause of death, with approximately 12.5% of children community development programs using a verbal autopsy questionnaire. dying before reaching the age of 5 (including outreach services to the A trained team of five interview- years, followed by Bolivia, with 9.0% household level, plus hospital referral ers visited the mothers or other care- (6). No other country in the Western care) serves as a possible model for givers of the deceased children and Hemisphere has more than 5.0% of its reaching the Millennium Develop- administered the verbal autopsy ques- infants dying before the age of 5 years ment Goal of decreasing the under- tionnaire after receiving informed con- (6). Hence, having accurate informa- five mortality rate worldwide by two- sent. The questionnaire consisted of tion on the cause of death for under- thirds by the year 2015.4 81 questions, in addition to ones to ob- five children would appear to be a pri- tain identifying information. Not all ority for the Government of Haiti and the questions were necessarily asked. for private health organizations work- MATERIALS AND METHODS For instance, if there was no cough or ing in the country. difficulty breathing, the interviewer This paper reports the findings from In the year 2000 a household survey skipped 7 questions. a population-based verbal autopsy of a random sample of 3 247 women, The questionnaire included more study using a standardized computer- representing 10% of the population questions than were needed for the ized diagnostic protocol carried out in of women of reproductive age in the computerized algorithm that was used the service area of the Hôpital Albert ASH service area, identified 144 deaths to assess the cause of death. The ques- Schweitzer (Albert Schweitzer Hospi- among children less than 5 years old tionnaire included open-ended ques- tal, or ASH), which is located in the tions about the symptoms and cause of rural Artibonite Valley of Haiti (Fig- death that were intended to assist the ure 1). ASH is the major source of pri- respondent in recalling the circum- 4 Perry H, Northrup R, Bryant J, Berggren W, mary health care and hospital services Berggren G. Reducing under-five mortality in stances prior to the death of the child. for the district known as the Unité severely impoverished settings through local The responses to these open-ended health and development programs: policy implica- Communale de Santé, Petite Rivière/ tions from the experience of the Hôpital Albert questions, however, were not used to Verrettes/La Chapelle, which contains Schweitzer. Article submitted for publication, 2004. determine the diagnosis of the cause of Rev Panam Salud Publica/Pan Am J Public Health 18(3), 2005 179 Original research Perry et al. • Assessing causes of under-five mortality in rural Haiti death. The questionnaire took an aver- TABLE 1. Steps and criteria for assigning causes of childhood death, Albert Schweitzer age of about 30 minutes to complete. Hospital service area, Haiti, 2001 (A copy of the questionnaire in either Diagnosis Criteria English or Haitian Creole can be ob- tained from the senior author.) Determination of cause of death The caregivers for 47 of the children among neonates who had died could not be located be- Step 1.a. All cases in which the death occurred during the first 28 days of cause they were temporarily away life are reviewed from home or had migrated. No care- Congenital abnormality Report of something physically wrong with the baby at birth givers refused to participate in the in- Neonatal tetanus Death between 4 and 14 days of age, with convulsions reported terview. The 97 children included in and (1) either normal crying at birth and stopped crying prior to the study did not differ significantly in death or (2) normal suckling at birth with cessation of suckling during the final illness reported terms of age, sex, and geographical lo- Accident No “congenital abnormality” or “neonatal tetanus” but death cation from the 47 children for whom reported by accident (drowning, burn, poison, injury from fall, verbal autopsies could not be ob- traffic accident, bite, violence, or other) tained. Among these 97 children, 34 Preterm birth No “congenital abnormality,” “neonatal tetanus,” or “accident” but died during the neonatal period, and birth occurring prior to the eighth month of pregnancy 63 died between 1 and 59 months of Delivery complication No “congenital abnormality,” “neonatal tetanus,” “accident,” or age.

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