Verbal/social autopsy study helps explain the lack of decrease in neonatal mortality in Niger, 2007–2010

The 2010 Niger National Mortality Survey (NNMS) found that from 1998 to 2009 the mortality rate of children less than 5 years old decreased significantly by 43.4%, from 226 (95% confidence interval CI 207–246) to 128 (95% CI 117–140) deaths per 1000 live births, but mortality of neonates less than 28 days old declined insignificantly from 39 (95% CI 32–46) to 33 (95% CI 28–39) deaths per 1000 live births [1,2]. The reduction in child deaths was attributed to improvements in the nutritional status of children less than 2 years old and increased coverage of key child survival interventions, including insecticide–treated bed nets, vitamin A supplementation, treatment of diarrhea with oral rehydration salts and zinc, careseeking for childhood pneumonia and fever or cough, and vaccinations. The rapid uptake of interventions was achieved through government policy decisions to implement the Integrated Management of Childhood Illness (IMCI) approach, integrated community case management for children with fever or malaria, suspected pneumonia and diarrhea, and to provide free health care for all pregnant women and children including scaling up access to a minimum package of high–impact interventions at integrated health centers and health posts. Interventions effective against neonatal mortality that were examined, including antenatal care, maternal tetanus toxoid, skilled birth attendance, early initiation of and exclusive breastfeeding, showed smaller increases in coverage to endpoint levels well below 50%, likely inadequate to decrease neonatal mortality [1]. In addition, an earlier study on the quality of maternal and newborn care found that few health workers present at birth had the knowledge, skills and access to basic equipment needed to effectively manage obstetric and newborn problems. Only 2.5% of Centres de Sante Integres (CSI), which are meant to have at least two nurses or midwives on duty at all times and which are the main health centers throughout the country intended to provide Basic Emergency Obstetric and Neonatal Care (BEmONC), had the full capacity for this service; and the national met need for EmONC stood at 2.3%, varying by region from 1.4% to 6.5% [3]. Health posts (Case de Santes), only about one–fourth of which have a nurse or midwife on staff and are not intended to provide EmONC, were not examined. Neither of these studies, however, examined several other interventions critical to neonatal survival nor did they assess the causes of and events leading up to the deaths of the newborns along the continuum of antenatal and delivery care of the mother and immediate postnatal care of the newborn, maternal complications and the severe newborn illnesses these can lead to, mothers’ perceptions and knowledge of how to respond to such critical events, their careseeking attempts for themselves and their newborns, and factors affecting these behaviors. The fact that maternal complications occur at a fairly constant level, severe enough to kill the mother in about 1.0% to 1.4% of pregnancies and to kill the baby at a much higher rate, and that it cannot be reliably predicted which women will experience these complications, is the basis for the maternal mortality reduction strategy of universal access to skilled birth attendance and emergency obstetric care when needed [4–7]. This strategy is no less important to the survival and health of the neonate, as it has been shown that pregnancy and delivery complications are the most important risk factors for neonatal mortality [8–12], with care directed at the intrapartum period providing the greatest mortality reduction [13]. Integrated maternal–neonatal care packages and linkages of community with facility maternal and newborn care provide further reductions in stillbirths and neonatal deaths [14,15]. The addition of newborn–specific strategies, including fetal monitoring, access to Caesarean section for fetal distress, clean delivery and cord care, neonatal resuscitation, early initiation of and exclusive breastfeeding, timely and appropriate thermal care of the baby, kangaroo mother care for stabilized preterm infants, recognition of and early careseeking for newborn illness, access to quality health care, and urgent referral to neonatal intensive care when needed, are required to maximize newborn survival [13,16–20]. Examining such vital information on maternal and newborn care provided for babies that died is needed to help explain why the deaths occurred and how they might have been prevented. Collecting comparison data for newborns that suffered a severe but non–fatal illness during the same time period as the deaths would require the difficult task of identifying households where such an illness occurred; and the inability to appropriately match deaths with other cases on the basis of illness severity and the timing of clinical signs has led to a misleading situation where one could falsely conclude that treatment increased mortality risk [21]. Moreover, promoting neonatal health and preventing the death of sick newborns requires well–proven interventions for which the population levels established by already–completed surveys can provide reasonable comparisons for the surveyed factors. Social autopsy (SA) is a method of inquiring about deaths that adds questions on household, community and health system determinants of mortality to complement a verbal autopsy (VA) interview on the illness signs and symptoms used to establish the biological cause of death [22]. We undertook to assess the biological causes and social determinants of recent neonatal deaths in Niger by conducting a verbal/social autopsy (VASA) study of neonatal deaths that occurred in 2007–2010 and were identified by the 2010 NNMS. Where possible, we compared the VASA findings for the deaths to the same factors for surviving children from the same cohort determined by recent population surveys. In this way, we sought to further explain the reasons for the limited decrease in neonatal mortality in Niger from 2007 to 2010.